Chapter q 20120327
-
Upload
auditi-pramanik -
Category
Documents
-
view
30 -
download
3
Transcript of Chapter q 20120327
— Chapter Q: Cesarean Delivery — 1
Chapter Q
Cesarean DeliveryNeil J. Murphy, MD, FACOG, FAAFP
Sarah K. Jorgensen, DO
Jeffrey D. Quinlan, MD, FAAFP
Published March 2012
OBJECTIVESAt the end of this lecture and workstation, participants will be able to:
1. Describe the anatomy and physiology relevant to cesarean delivery.
2. List eight steps leading to cesarean delivery of a fetus.
3. Discuss five intra-operative and five post-operative complications of cesarean delivery.
4. Describe the indications for perimortem cesarean delivery.
INTRODUCTIONThe Joint American Academy of Family Physicians (AAFP)/American College of Obstetricians
and Gynecologists (ACOG) Recommended Curriculum Guidelines for Family Medicine Residents:
Maternity and Gynecologic Care describes core and advanced obstetric training for family physi-
cians.1 This chapter will review cesarean delivery within the contexts of family physicians, OB/GYN
residents, CNMs or registered nurses requesting cesarean delivery consultation, surgical first assist-
ing, performance of cesarean delivery as the primary surgeon, perimortem cesarean delivery, and
vaginal trial of labor after cesarean (TOLAC).
HistoryThe origin of the term “cesarean” is not entirely clear. It is unlikely that Julius Caesar was born by
abdominal delivery, as this was almost universally fatal for the parturient during that era and Caesar’s
mother is known to have survived his birth.2 Another possible origin of the term is the Latin verb cae-
dere, which means “to cut”. Others believe the term originated from the Roman custom, Lex Cesare,
which mandated postmortem operative delivery when mothers died during childbirth, so that mother
and child could be buried separately.
The term “cesarean section” is also a matter of discussion. The term is a tautology — using different
words to say the same thing twice — where the additional words fail to provide additional clarity while
repeating a meaning. In this case both words refer to an incision. A more proper term for the proce-
dure is ‘cesarean delivery’.
EPIDEMIOLOGYFrequencyThe cesarean delivery rate in the U.S. increased from 4.5 percent in 1965 to an all-time high of 32.3
percent in 2008.3-4 This represents an increase of 56 percent from the 20.7 percent rate in 1996.4
The increase is a result of both the increase rate of primary cesarean deliveries and the decrease in
vaginal birth after cesarean.
slide 1
slide 2
slide 3
2 — — Chapter Q: Cesarean Delivery
Goals for Cesarean Delivery RatesThe ACOG Task Force on Cesarean Delivery Rates recommends using case mix adjusted rates and
has offered the following benchmarks:5
• Nulliparous women at 37 weeks of gestation or greater with singleton fetuses with cephalic
presentation. The national delivery rate for this group was 17.9 percent; the expert working
group goal at the 25th percentile for this group is 15.5 percent.
• Multiparous women with one prior low transverse cesarean delivery at 37 weeks of gestation
or greater with singleton fetuses with cephalic presentations. The national 1996 TOLAC rate
for this group was 30.3 percent; the expert working group goal at the 75th percentile is 37
percent.
MORBIDITY AND MORTALITYThe maternal mortality rate for elective repeat cesarean delivery is 13.4 per 100,000 births.6 Half of
these deaths are related to intraoperative complications, while others are related to anesthetic and
post-operative complications. In recent years, there has been a shift in the etiology of deaths from
hemorrhage and infection to thromboembolic events.
INDICATIONSThe most common indications for cesarean delivery in North America are repeat cesarean
(30 percent), dystocia or failure to progress (30 percent), malpresentation (11 percent), and Category
III fetal heart rate tracings (10 percent).7 Other indications are listed in Table 1. Many indications
are dependent on other clinical factors, e.g., viral load with HIV, unable to meet criteria for vaginal
breech delivery and current status of medical conditions.
Table 1. Common Indications for Cesarean Delivery
FetalCategory III Fetal Heart Rate Tracing
Malpresentation
• Transverse lie
• Breech
• Brow
• Face/Mentum posterior
Cord prolapse
Human Immunodeficiency Virus
Active herpes virus
Congenital anomaliesVasa previa
Maternal-FetalFailure to progress in labor:
• Arrest of descent
• Arrest of dilation
Placental abruption
Placenta previa
Conjoined twins
Perimortem
MaternalRepeat cesarean delivery
Contracted pelvis
• Congenital
• Fracture
Obstructive tumors
Abdominal cerclage
Reconstructive vaginal surgery
Medical conditions (e.g., cardiac, pulmonary, thrombocytopenia)
CONTRAINDICATIONSThere are few contraindications for cesarean delivery. A guiding principle is “what is best for the
fetus is what is best for the mother”. If the mother is medically unstable and the fetus is non-viable,
then it is recommended that the maternal condition be stabilized regardless of fetal consideration. If
the fetus is of a gestational age consistent with viability, then the maternal condition should also be
stabilized first and delivery considered only for obstetric indications. The exception to this dictum is
perimortem cesarean delivery.
slides 4-6
— Chapter Q: Cesarean Delivery — 3
slide 7
slides 8-9
TIMING OF ELECTIVE CESAREAN DELIVERYWhile term pregnancy is defined as 37 weeks of gestation or later; elective cesarean delivery is
typically not performed prior to 39 weeks gestation secondary to the risk of fetal lung non-maturity.
Despite this risk, Tita et al demonstrated that over one third of elective cesarean deliveries com-
pleted at their facility between 1999 and 2002 were done before 39 weeks gestation. Additionally,
they demonstrated that delivery prior to 39 weeks was associated with increased rates of respiratory
problems, sepsis, hypoglycemia, and either prolonged hospitalization or requirement for increased
level of care.90 Therefore, cesarean should not be performed prior to 39 weeks gestation unless
there are medical indications for either the mother or fetus.
For patients with complicating factors (e.g. placenta previa or prior classical uterine incision), risk of
maintaining the pregnancy to 39 weeks may outweigh the risks to the mother and fetus if delivered
prior to 39 weeks. In these situations, consideration should be given to obtaining an amniocentesis
for fetal lung maturity beginning at 36 weeks. Once fetal lungs are determined to be mature or the
patient reaches 38 weeks of gestation, cesarean delivery should be performed.
ANATOMY AND PHYSIOLOGYMany alterations in maternal cardiovascular physiology during pregnancy are relevant to cesarean
delivery. (See Chapter K. Maternal Resuscitation) These physiologic changes increase maternal
blood volume and flow in the pelvic organs, rendering the woman more susceptible to serious
hemorrhage during cesarean delivery. The surgical anatomy is described in this chapter with each
aspect of the procedure. An understanding of pelvic blood supply of pelvic blood supply is essen-
tial for physicians performing a cesarean delivery.
Uterine ArteryThe aorta bifurcates into bilateral common iliac arteries at the level of the fourth lumbar vertebra.
The common iliac divides into external and internal iliac arteries. The internal iliac or hypogastric
artery drops medio-inferiorly along the border of the psoas muscle and divides into anterior and
posterior divisions. The anterior division has both parietal and visceral branches of variable origin.
The uterine artery, a main visceral branch of the anterior division of the hypogastric artery,
descends for a short distance, enters the base of the broad ligament, and turns medially to the
lateral aspect of the uterus. The relationship between the uterine artery and ureter is surgically sig-
nificant. About two centimeters lateral to the cervix, the uterine artery crosses over the ureter. The
ureter can be injured in the process of clamping and ligating the uterine vessels in postpartum hem-
orrhage or during hysterectomy.
The inferior branch of the uterine artery supplies the upper vagina and the lower cervix, while
the marginal branch traverses the lateral aspect of the uterus before dividing into three terminal
branches: ovarian, tubal, and fundal. Near the upper lateral portion of the uterus, the ovarian artery
anastomoses with the ovarian branch of the uterine artery. Throughout its length, the marginal
branch is a convoluted vessel with numerous branches penetrating the body of the uterus, including
one large branch that extends to the upper portion of the cervix.
4 — — Chapter Q: Cesarean Delivery
Ovarian Artery The ovarian artery is a direct branch of the aorta and enters the broad ligament through the infun-
dibulopelvic ligament. At the ovarian hilum, the ovarian artery divides into ovarian branches and a
main branch that traverses the broad ligament.
Uterine and Ovarian Veins The lateral uterus is composed largely of venous sinuses. These sinuses coalesce into arcuate
veins that unite to form the uterine vein. Several large uterine veins accompany the uterine artery
and empty into the hypogastric vein, which empties into the common iliac vein. The ovarian vein
collects blood from the upper part of the uterus through a large pampiniform plexus in the broad
ligament. The right ovarian vein empties into the vena cava, while the left ovarian vein empties into
the left renal vein.
Vaginal Blood Supply The vagina receives blood from the inferior extension of the uterine artery along the lateral sulci of
the vagina and from a vaginal branch of the hypogastric artery. These form an anastomotic arcade
along the lateral aspect of the vagina at the 3:00 and 9:00 o‘clock positions. Branches of these ves-
sels also merge along the anterior and posterior vaginal walls.
PHYSICAL FINDINGS AND DIAGNOSISHistoryHistory should be obtained that is pertinent to impending surgery, including medical, surgi-
cal, obstetric, gynecologic, family, drug habits, transfusion, medication, allergy, and anesthetic.
Information about the current obstetric indication is required, e.g. length of labor and duration of
ruptured membranes.
Physical ExaminationThe physical examination for cesarean delivery should address major medical, obstetrical, and
anesthetic concerns. The operating team must be cognizant that regional anesthesia may be con-
verted to general anesthesia at any time during the procedure. A vaginal exam should be performed
in all laboring patients just prior to surgical draping, to assure that sufficient progress in labor has
not occurred that would permit vaginal delivery.
Ancillary TestsPre-operative laboratory evaluation should include hemoglobin, blood type, and Rh factor. A blood
clot tube should be present in the blood bank for blood typing and antibody screening in the event
that transfusion is required. HIV status should be known on all prenatal patients so that measures
can be taken to decrease the risk of vertical transmission of infection. If the cesarean delivery is
being considered because of abnormal fetal heart monitoring that does not resolve with conserva-
tive measures then additional testing may be indicated because of the high rate of false positive
tests with electronic fetal monitoring (EFM). (See Chapter E. Intrapartum Fetal Surveillance) Methods
for confirmatory testing include fetal response to scalp or acoustic.
slide 10
— Chapter Q: Cesarean Delivery — 5
PROCEDUREPre-Operative and Non-Surgical ConsiderationsThe patient should be prepared as for any major abdominal procedure. Additional fluids are neces-
sary for regional anesthesia, increased insensible loss with labor, and intra-operative loss of 1,000 cc
per hour due to exposed viscera and blood loss. (Table 2)
Table 2. Pre-operative Preparation/Orders
Vital signs and non-stress test on admission
Anesthesia consultation
Nothing per mouth (except non-particulate citrate antacid, Bicitra®)
Intravenous: Lactated ringers at 125 cc/hr; if regional anesthetic, then bolus of IV fluids per Anesthesia
Bicitra® 30 cc per mouth 1 hour pre-op, or on call to OR
Cefazolin (Ancef®) one gram intravenous to be given 15 to 60 minutes prior to skin incision
Place patient in left lateral decubitus position
Insert bladder catheter
Clip lower abdominal hair as needed
Sequential compression devices on lower extremities
Lab: Complete blood count, blood type and screen
Patient education: cesarean delivery
Fluid administration prior to epidural or spinal anesthesia in normotensive patients usually involves
a 1,000 cc bolus of isotonic fluids. Isotonic fluids are good first-line agents in the event of excessive
bleeding, but blood product replacement is necessary for any ongoing blood loss greater than
1,000 ml. Use of prophylactic antibiotics has been shown to decrease the incidence of fever, endo-
metritis, wound infection, urinary tract infection and serious post operative infection after cesarean
delivery.8 Both ampicillin and first generation cephalosporins have similar efficacy in reducing post-
operative endometritis. There does not appear to be added benefit in utilizing a broader spectrum
agent or a multiple dose regimen.9 All cesarean delivery patients should receive intravenous anti-
biotics prior to skin incision, unless the patient is already receiving appropriate antibiotics (e.g., for
chorioamnionitis) or there is not adequate time due to a “crash” cesarean delivery10-11 Preincision
prophylaxis is advantageous for the mother and not harmful to the neonate therefore the prior prac-
tice of administering antibiotics after cord clamping has been abandoned. Consider clindamycin
in patients who are penicillin allergic with a history of anaphylaxis, urticaria or other life threatening
reaction, if a procedure exceeds four hours, then re-dosing should be considered.
Infective endocarditis prophylaxis is no longer recommended for vaginal or cesarean delivery in the
absence of infection, regardless of the type of maternal cardiac lesion.12 Abdominal hair removal often
is not necessary. If hair is removed, it should be removed in the operating room and not the evening
before the procedure. The hair should be clipped and not shaved to decrease the risk of infection.
Informed ConsentThe surgeon should thoroughly discuss the risk and benefits of the procedure in both non-medical
and medical terminology with the patient and a family member, if available. The counseling is best
documented in narrative form, though a preprinted form can be used. Preoperative documentation
should be signed and dated by the patient and surgeon. Documentation should include diagnosis,
slide 11
6 — — Chapter Q: Cesarean Delivery
procedure, common and important risk factors, alternatives to the proposed procedure, and other such
procedures as anticipated as being possibly needed in the judgment of the surgeon (e.g. tubal ligation
or oophorectomy for known adnexal mass). The risk factors can be simplified to bleeding, infection,
internal organ damage, anesthesia risk, hysterectomy, injury to fetus and risk of maternal death.
CESAREAN DELIVERY PROCEDUREThe primary surgeon and assistant should both carefully review the following basic skill discussion.
(Table 3)
Table 3. Techniques of Cesarean Delivery
Prepare patient
• Informed consent
• Nothing by mouth except non- particulate antacid, anesthesia, bladder catheter
• Clip hair, cleanse skin, left lateral decubitus position
• Cefazolin IV within 60 minutes prior to skin incision
• Sequential compression devices on lower extremities
Abdominal wall incision
• Joel-Cohen (Misgav Ladach modification)
• Modified Pfannenstiel
• Midline vertical
• Others: Maylard, Cherney
Fascial incision
• Joel-Cohen: small midline fascial incision, stretch tissue
• Pfannenstiel: long transverse incision, separate rectus muscle/ sheath, stretch rectus muscles apart
Peritoneal incision
• Parietal: Longitudinal; Transverse (Joel-Cohen)
• Visceral: Transverse vesicouterine; +develop blad-der flap
Uterine incision
• Low transverse
• Classical
• Low vertical
Elevate the fetal presenting part
• Elevate presenting part, maintain flexion if cephalic
• Second assistant to dislodge presenting part, if deeply seated
Apply fundal pressure
• Administer oxytocin after delivery of presenting part
Clamp and cut umbilical cord
• Obtain cord blood for:
– Type and Direct Coombs, if clinically indicated13
– Cord pH from loop of cord obtained prior to cord blood sample
• Delivery of placenta
• Assisted spontaneous
• Manual
Cleanse uterine cavity
• Place ring forceps at apices of uterine incision
Uterine closure
• Externalize uterus (optional)
• Inspect for possible extensions
• One to two layers of absorbable suture
Inspect pelvic and abdominal contents
• Remove foreign material from peritoneal cavity
• Sponge and needle count
Peritoneal closure (optional)
• Visceral (bladder flap)
• Parietal
Fascial closure
• Single non-locking
• Two lines of suture meeting in the midline, non-locking (optional)
Subcutaneous (optional, if tissue greater than two centimeters)
• Close dead space if > 2 cm
• Irrigate subcutaenous tissue
Skin closure: subcuticular, staples, widely spaced mattress sutures
Apply sterile dressing
slide 12
— Chapter Q: Cesarean Delivery — 7
slide 13
slide 14
slide 15
ABDOMINAL WALL INCISIONOptions for the abdominal wall incision include the modified-Pfannenstiel, Joel-Cohen, and midline
vertical incisions, plus several variants of these incisions.14 The midline vertical incision was said to
be quickest abdominal wall incision, but most experienced surgeons can perform either the Joel-
Cohen within seconds or the modified Pfannenstiel within minutes.
Modified Pfannenstiel The modified-Pfannenstiel incision is made three centimeters above the pubic symphysis. The inci-
sion is extended beyond the lateral borders of the rectus muscles in a curvilinear fashion to within
two to three centimeters inferior and medial of the anterior superior iliac crests. The incision may be
placed under the pannus in very obese patients, however this area is heavily colonized with bacteria
and may be difficult to prepare surgically, keep dry, and to inspect in the post-operative period.
The subcutaneous tissues are completely separated from the fascia and a transverse incision is
made through the fascia. The fascial sheath is then completely separated from the underlying
rectus muscles by blunt and sharp dissection to the umbilicus and caudad until the pubis is pal-
pable. Blood vessels perforating through the muscles can be ligated with electrocautery, or cut and
clamped as required for hemostasis. The peritoneum is elevated and sharply opened longitudinally
in the midline.
Joel-Cohen (Misgav Ladach Modification) The Joel-Cohen abdominal wall incision, modified by the Misgav Ladach hospital, emphasizes
stretching tissue within existing planes, rather than sharp dissection.15 (Table 4)
Joel-Cohen-based cesarean delivery compared with Pfannenstiel cesarean delivery was associated
with reduced blood loss, operating time, time to oral intake, fever, duration of postoperative pain,
analgesic injections, and time from skin incision to birth of the neonate.14
Available evidence suggests that the Joel-Cohen–based techniques (Joel-Cohen, Misgav-Ladach,
and modified Misgav-Ladach) have advantages over Pfannenstiel and traditional CS techniques in
relation to short-term outcomes. There is no evidence in relation to long-term outcomes.14
Table 4. Misgav Ladach Method of Cesarean Delivery16
1. Modified Joel-Cohen opening of the abdomen
2. Parietal peritoneum opened transversely
3. No abdominal swab used
4. Lower uterine segment transverse incision
5. Uterus sutured continuously in one layer
6. Visceral and parietal peritoneum left open
7. Non-locking continuous closure of the fascia
8. Few widely spaced skin stitches
Reprinted from the International J of Gynecol and Obstet, 1997;57:p 273, Federici D, Lacelli B, Muggiasca A, et al: Cesarean section using the Misgav Ladach method, with permission from Elsevier.
8 — — Chapter Q: Cesarean Delivery
This technique has particular advantages in remote or rural areas because it requires fewer instru-
ments than other methods for opening the abdominal wall, and can be performed quickly. The
modified Joel-Cohen begins with a transverse incision, 15 to 17 centimeters long, made three centi-
meters below the anterior superior iliac crests. The skin is opened superficially, followed by sharp
dissection of the subcutaneous fat to open the fascia in the midline only.
The fascia is extended sharply two to three centimeters under the intact subcutaneous tissue. After
opening the fascia, the remaining subcutaneous tissue, fascia, and rectus muscles are dissected
bluntly. The fascia is best opened with cephalad and caudad pressure followed by transverse pres-
sure on the rectus muscles laterally.
The incision is very rapid and results in less blood loss than other techniques. There is a decreased
need for transfusion and less risk of HIV transmission because the technique simply stretches tis-
sues transversely.
Decreased tissue damage also leads to less post-operative analgesia and early resumption of feed-
ing and activity. Joel-Cohen-based cesarean delivery compared with Pfannenstiel cesarean delivery
was associated with reduced blood loss, operating time, time to oral intake, fever, duration of post-
operative pain, analgesic injections, and time from skin incision to birth of the neonate.14
Midline Vertical The midline-vertical skin incision extends from the pubic symphysis to within two centimeters of
the umbilicus. The fascia is elevated and sharply dissected from the pubis to the umbilicus. This
midline-vertical abdominal wall incision can be performed rapidly, and provides excellent exposure
of the pelvis and sidewalls.
Other IncisionsThe transverse Maylard rectus-cutting incision begins with a curvilinear skin incision that extends 18
to 19 centimeters between the anterior superior iliac crests. The Maylard offers maximal exposure for
abnormal lie, multiple gestation, or macrosomia. In the transverse Cherney incision, the rectus mus-
cles are detached from their insertion at the pubic symphysis. The transversalis fascia and peritoneum
are incised transversely in the Cherney, as opposed to the longitudinal Pfannenstiel approach.
PERITONEAL INCISIONParietal PeritoneumThe parietal peritoneum should be entered as high as possible to avoid inadvertent bladder injury,
especially in repeat procedures. After the Pfannenstiel and midline-vertical incisions, the parietal
peritoneum is sharply incised from the umbilicus to the bladder. In the Joel-Cohen, the peritoneum
is stretched in a transverse direction.
Urinary bladder The urinary bladder can be divided into two portions, the dome and base. The base of the bladder,
which rests on the upper vagina and cervix, contains the trigone and is contiguous with the muscle
of the vesical neck and urethra. The muscular dome of the bladder is relatively thin when distended.
The bladder base is thicker and varies less with distention. The bladder is encountered twice before
slide 16
— Chapter Q: Cesarean Delivery — 9
delivery. Initially the surgeon visualizes the bladder when opening the peritoneum and it is encoun-
tered again when dissecting the bladder flap off the lower uterine segment. The extent of the blad-
der can be confirmed by palpation of the catheter bulb or transillumination.
Visceral PeritoneumOmission of the bladder flap provides short-term advantages such as reduction of operating time
and incision-delivery interval, reduced blood loss, and need for analgesics.17 Long-term effects
remain to be evaluated. In those cases in which a cesarean hysterectomy is planned, then develop-
ing a bladder flap may be helpful.
If deemed necessary, the vesico-uterine peritoneum is elevated and opened transversely one centi-
meter above the bladder reflection onto the lower uterine segment. The bladder flap is bluntly and
sharply developed transversely 10 to 12 centimeters, then inferiorly five centimeters, to the level of
the bladder’s apposition to the cervix.
UTERINE INCISIONCesarean delivery is performed via one of several uterine incisions. The most common is a low-
transverse or Kerr incision. A less common surgical approach is the “classical” or vertical uterine
incision. Both can be performed through any abdominal incision.
Uterus As the uterus enlarges, it reaches almost to the liver displacing the intestines laterally and superiorly.
The uterine musculature is arranged in three layers. The muscle cells in the middle layer are interlaced
such that when they contract after delivery, they constrict the perforating blood vessels. When a preg-
nant woman is supine, however, her uterus falls back to rest upon the vertebral column and the great
vessels, especially the aorta and the inferior vena cava. With ascent from the pelvis as pregnancy pro-
gresses, the uterus undergoes dextro-rotation, resulting in the left margin facing anteriorly.
Low transverse incision The low-transverse Kerr incision is made in the inactive or non-contractile lower uterine segment.
Most cesarean deliveries use a low-transverse uterine incision because of the ease of delivery and
low rate of both immediate and subsequent wound dehiscence. The low incidence of dehiscence
occurs because the low-transverse incision avoids the active uterine segment. It also requires less
surgical repair, results in less blood loss and is less likely to result in formation of adhesions to the
bowel or omentum.
The lower uterine segment is delicately scored in the median aspect with a scalpel, one to two centi-
meters from the upper margin of the bladder taking care to avoid injury to the fetus. If the lower uterine
segment is very thin, fetal laceration injury, which occur in between 0.7 and 1.9 percent of cesarean
deliveries,18-19 can be avoided by elevating the lower uterine segment with Allis clamps. Another
method involves cutting to within a few cells of the uterine cavity, then tapping the closed blades of a
pair of scissors against the incision. Opening and closing the blunt tips of the scissors will not hurt the
baby, nor enter the amniotic cavity, but will penetrate the remaining layers of lower segment.
slide 17
slide 18
slide 19
10 — — Chapter Q: Cesarean Delivery
slide 20
slide 21
slide 22
The uterine incision is extended bluntly using two fingers. Blunt expansion of the uterine incision
by separating the fingers in a cephalad-caudad direction results in less unintended extension and
blood loss than expansion in a transverse direction.20 The incision should extend approximately 10
centimeters transversely and slightly cephalad in a curvilinear fashion. If the uterine wall is thickened
or there is need for an extension, then bandage scissors should be used. In this case, care should
be taken to avoid injury to the fetus or umbilical cord. The incision should be large enough to avoid
fetal injury and to avoid inadvertent extension into lateral vessels. If it is necessary to extend the
uterine incision, then the first superior curvilinear incision should be to the right to avoid the lateral
vessels because of the dextro-rotation. Some surgeons place laparotomy sponges in the peritoneal
cavity to minimize contamination with chorioamnionitis or thick meconium. All laparotomy sponges
placed in the abdomen should have radio-opaque tails. The surgeon should know the location of
every sponge in the abdomen, and not simply rely on the operating team’s count.
Classical / Vertical Incision The classical uterine incision is made vertically into the active myometrium. The classical incision
is indicated in significant prematurity with a poorly developed narrow lower uterine segment, dense
adhesions, or structural uterine abnormalities, e.g., myoma in the lower uterine segment or Bandl’s
contractile uterine ring. The classical incision may be used in some cases of anterior placenta pre-
via and malpresentation, e.g., back-down transverse lie, pre-term breech, and interlocking twins.
Low vertical incision The low vertical incision begins as inferiorly as possible to avoid the active uterine segment. The
incision is usually made about two centimeters above the bladder, and is carried as far cephalad as
necessary to allow facile delivery. This may be performed completely in the lower uterine segment
and repair may be as strong as the low transverse incision. Shipp et al suggest that there is no
increased risk of uterine rupture in future pregnancies when a low vertical uterine incision is used
compared to a low transverse incision.21
The major disadvantage of the low vertical incision is the possibility of extension cephalad into the
uterine fundus or caudally into the bladder, cervix, or vagina. It is also difficult to determine that the
low vertical incision is truly low, as the separation between lower and upper uterine segments is not
easily identifiable clinically.
Anterior Placenta ManagementIf an anterior placenta is present, it should be dissected or separated from the uterine wall facilitating
exposure of the fetus. There is a short-term risk of fetal hemorrhage unless delivery is rapid. If the
placenta is lacerated, the operator should cut through the rest of the placenta and quickly delivery the
infant and clamp the cord. A vertical incision may be necessary. A preoperative ultrasound for placen-
tal location may be helpful.
DELIVERY OF THE FETUSCephalic Presentation To deliver an infant from a cephalic presentation, remove the retractors and elevate the presenting
part with the operator’s hand, after which the assistant applies transabdominal pressure to the uter-
ine fundus. If the presenting part is deeply applied to the cervix, then gently insinuate the hand into
the uterus with side-to-side motions to break the suction and act as lever to elevate the presenting
— Chapter Q: Cesarean Delivery — 11
part. The operator should avoid using the uterine incision as a fulcrum for elevating the presenting
part to avoid extension of the uterine incision. The assistant applies fundal pressure when the oper-
ator feels the presenting part is elevated enough that the force will push the presenting part up and
out of the incision instead of deeper into the pelvis. Flexion is desirable in both occiput posterior or
anterior. Too much manipulation of a thin lower uterine segment may lead to a deep cervical lacera-
tion. If the presenting part is deeply seated in the pelvis, then an additional assistant may need to
go under the operative drapes to manually dislodge the presenting part cephalad via the vagina.
If the presenting part is high, then a vacuum extractor or single blade of a Simpson forceps may be
helpful. Deliver the torso by gently working the shoulders out one at a time with continued fundal
pressure. The infant is transferred to an attendant after the umbilical cord is clamped and cut.
Breech Presentation The presenting part should be confirmed pre-operatively with ultrasound, as a breech presentation
will require a slightly larger abdominal wall and uterine incision for adequate exposure. A vertical
uterine incision may be necessary if the lower uterine segment is not well developed, e.g., very pre-
term. The techniques for a breech cesarean delivery are similar to those used in a breech vaginal
delivery. (See Chapter G. Malpresentation) The abdominal and uterine incisions can be extended if
delivery of the fetal head is difficult. The uterine incision can be extended vertically into the active
myometrium, perpendicular to the transverse uterine incision in an inverted ‘T’ shape, or extended
perpendicularly to the uterine vessels in a ‘J’ shape. These extensions should be noted in the opera-
tive report and the patient informed that repeat cesarean is indicated in future pregnancies due to
increased risk of uterine rupture.
After Delivery of the FetusCord blood is obtained and may be sent for infant blood type and Rh status, Coombs test, HIV or
RPR based on facility guidelines.13 In addition, a 10 to 15 centimeter segment of umbilical cord may
be saved for blood gas measurement. To obtain a sufficient amount of arterial pH specimen, the
cord should be clamped close to the placenta.
DELIVERY OF THE PLACENTAAn infusion of 20 to 40 units of oxytocin (Pitocin®) in a liter of isotonic crystalloid is begun imme-
diately upon delivery. Assisted spontaneous delivery of the placenta involves fundal massage and
gentle traction on the umbilical cord. Manual extraction of the placenta may be necessary on occa-
sion, but assisted spontaneous delivery of the placenta with gentle cord traction is preferred.
Assisted spontaneous delivery of the placenta with cord traction at cesarean delivery has advan-
tages compared to manual removal. It results in fewer instances of endometritis; less blood loss;
less decrease in hematocrit levels postoperatively; shorter duration of hospital stay, and it does not
add significantly to operative time.22
The uterine cavity should be inspected and cleansed with a laparotomy sponge. Routine manual/instru-
mental cervical dilatation before closing the uterus in an elective cesarean delivery is unnecessary. A
RCT reported that this practice does not improve blood loss and postoperative infectious morbidity.23
slide 23
12 — — Chapter Q: Cesarean Delivery
REPAIR OF THE UTERUSThe uterus can be repaired within the peritoneal cavity or while externalized. There is no evidence
from the latest Cochrane review to make definitive conclusions about which method of uterine closure
offers greater advantages.24 Externalization offers increased exposure of the uterus and adnexa, plus
ease of fundal massage.
No differences in complication rates were found between extraabdominal and intraabdominal repair
at cesarean delivery.25 In addition, there was no difference in rates of intraoperative nausea/vomiting
among those who underwent cesarean delivery under regional anesthesia.25
Significant bleeding points should be clamped with ring forceps and the fundus of the uterus covered
with a moist sponge. The margins of the uterine incision should be identified. The uterine incision is
closed with a single layer of zero or number one absorbable suture in a running-locked manner.
The surgeon traditionally sutures toward her/himself. To insure that each apex is closed, a suture
should be placed just beyond each apex. Some surgeons add a second line of sutures to imbricate
the incision and for hemostasis. There is conflicting evidence regarding the advantage of the second
suture layer.26-27 Patients who have a single layer closure may be at increased risk of uterine rupture
during the next pregnancy compared with those who undergo a two-layer closure. For women who
would consider a trial of labor after a previous cesarean delivery, a two-layer uterine closure is sug-
gested, although data to support this is not conclusive. Closure of a vertical incision requires a layered
closure, using successive layers of zero or number one absorbable suture.
CLOSURE OF PERITONEAL, FASCIAL, SUBCUTANEOUS AND SKIN LAYERSFollowing exploration of the pelvis and abdomen, all foreign material should be removed from the
pelvis and copious lavage accomplished, especially if chorioamnionitis is present. It is essential to
confirm that needle and sponge counts are correct. In the past, the vesicouterine and parietal peri-
toneum were closed with a 2-0 absorbable suture. Closure of the peritoneum offers no advantage,
and increases operative time, febrile morbidity, rates of cystitis, narcotic use, antibiotic use, and
length of stay in the hospital. There was improved short-term postoperative outcome if the perito-
neum was not closed.28
The fascia is closed with a zero or number one non-locked continuous long-lasting absorbable suture,
e.g., polyglactin 910 (Vicryl®). Sutures should be placed at one centimeter intervals approximately one
and one half centimeters from the margin of the cut fascia. Some surgeons close the fascia with two
lines of suture that meet in the midline. Many surgeons perform a Smead-Jones mass closure with a
number one non-absorbable suture for vertical incisions at high risk of dehiscence.
Suture closure of subcutaneous fat during cesarean delivery results in a 34 percent decrease in risk
of wound disruption in women with fat thickness greater than 2 cm.29-30 The skin can be closed with
staples, subcuticular 4-0 absorbable sutures, skin adhesive, or with widely spaced mattress sutures.
Studies have shown no clear difference in strength of incision closure or cosmetic appearance with
the various techniques.31-34
slides 24-25
slides 26-28
— Chapter Q: Cesarean Delivery — 13
TIPS FOR SURGICAL ASSISTANCE AT CESAREAN DELIVERYThe surgical assistant plays a key role in cesarean delivery. (Table 5) The key elements are main-
taining excellent exposure and maintaining the flow of the procedure, and being prepared for the
unexpected. (Table 5)
Table 5. Tips for Surgical Assistance at Cesarean Delivery
Exposure Lateral aspects of the following on both opening and closing: Rectus fascia, vesicouterine peritoneum, uterus
Rectus fascia (with modified Pfannenstiel incision) Elevate fascia with Kocher clamps Blunt dissection of rectus muscle from fascia Provide counter traction on muscle while surgeon dissects fascia from muscle Re-check under fascia for bleeding before closure
Uterine incision Suction blood and fluid from incision as surgeon delicately scores uterus sharply
Delivery Apply fundal pressure when requested Assist with clamping and cutting umbilical cord Obtain cord blood samples
If uterus is externalized after delivery Hold tension on fundus while keeping the uterine incision dry for visualization of repair Scrub technician should create exposure with bladder blade
Uterine closure If surgeon is locking sutures, then loop suture over needle each pass
Knot tying Three loops or throws for chromic gut suture Four loops or throws for Vicryl®, with first being a double throw or surgeon’s knot
TECHNICAL PITFALLSClosing the Uterine IncisionA common error is placement of sutures beyond the uterine incision. This may result in increased
bleeding from the lateral uterine vessels, and increases ureteral injury. An inexperienced operator, or
one operating with inadequate exposure, may inadvertently suture incorrect tissue. The uterine inci-
sion, and any extensions, should be carefully identified prior to closure. Poor exposure may result in
suturing the upper edge of the uterine incision to a prominent posterior wall of the uterus.
Malpresentation DeliveriesSome experienced clinicians consider converting a breech or transverse to cephalic after opening
the abdomen but before the uterine incision. Intraoperative version prior to uterine incision may
avoid a traumatic delivery, a classical uterine incision, an inverted “T” incision, or an extension.
Adequate abdominal wall and uterine exposure is critical for atraumatic delivery of a malpresenta-
tion. A skilled assistant must be available to avoid hyperextension and assist with fetal head flexion
when performing a cesarean delivery of an infant in breech presentation.
slides 29-31
slide 32
slide 33
14 — — Chapter Q: Cesarean Delivery
slide 34
Postoperative CareWhile it was customary for fluids and/or food to be withheld for a period of time after abdominal
operations, there was no evidence from randomized trials reviewed to justify a policy of withholding
oral fluids after uncomplicated cesarean delivery.35
Choice of ProcedureRandomized-controlled studies have shown that many aspects of the traditional cesarean delivery
practiced in the US are unnecessary. The modified Joel-Cohen cesarean delivery avoids these
steps, and is associated with less operative time, fewer complications, and shorter length of stay.14
Uterine closure with interrupted or single-layer continuous locking suture has short-term benefits.
However, the evidence from observational studies of an increased risk of scar rupture may favor the
use of double-layer closure pending evidence on this outcome from randomized trials.27
Where no clear benefits of one method over another have been shown, the choice may have been
influenced by the clinical setting. For example, in a resource-constrained environment where large
numbers of cesarean deliveries are performed, a cost-effective choice may be spinal analgesia
and Joel-Cohen–based surgical methods, which require only two lengths of suture material for the
operation, and double-layer closure of the uterus.14
Summary of Cesarean Delivery Techniques1. No preoperative hair removal; or clipping or depilatory creams on the day of surgery or the
preceding day (no shaving).
2. No specific antiseptic for preoperative bathing.
3. Antibiotic prophylaxis with ampicillin or a first-generation Cephalosporin.9
4. Double gloving is advised in areas with high rates of bloodborne infections to achieve fewer
perforations in inner glove and prevent needle stick injuries.
5. Transverse lower abdominal wall opening and uterine opening using Joel-Cohen–based methods.15
6. Bladder peritoneum may be reflected downward or not.17
7. Placental removal with cord traction.22
8. Intraabdominal or extraabdominal repair of the uterus.24
9. Uterine closure with interrupted or single-layer continuous locking suture has short-term benefits.
However, the evidence from observational studies of an increased risk of scar rupture may favor
the use of double-layer closure pending evidence on this outcome from randomized trials.26-27
10. Nonclosure of both peritoneal layers.28
11. Closure of the subcutaneous tissues if greater than 2 cm thickness.29-30
12. No routine drainage of the subcutaneous tissues.36
13. Skin closure with subcuticular or interrupted sutures, staples, or tissue adhesive.31
14. No withholding of oral fluids after surgery.35
— Chapter Q: Cesarean Delivery — 15
Poor Documentation in Operative ReportsAccurate documentation of the operative procedure can prevent confusion and complications in the
future. In particular, the surgeon should take care in describing the uterine incision. For example,
“repeat low-transverse cesarean delivery” can be ambiguous to some. It could mean:
• the prior incision was a classical or low vertical and the current procedure was a “repeat”
cesarean performed via a low-transverse incision, or
• the previous operation was a low-transverse incision and the same procedure was used in the
current procedure.
In the first example, the patient should never undergo TOLAC, while in the second she is a TOLAC
candidate. A better description of the procedure would be “Low-transverse uterine incision. Repeat
cesarean delivery” It is also important to properly document the extent of active uterine segment
involved in a low-vertical incision, the extent of an inverted “T” incision, and the nature of any uterine
lacerations. The dictation should also contain a brief description of the ovaries, tubes, and surround-
ing structures.
INTRAOPERATIVE COMPLICATIONSIntraoperative injuries are uncommon, but they can still occur despite careful attention to technique. The
operative team is responsible for identifying and repairing injuries, or seeking appropriate assistance.
HemorrhageThe most common cause of hemorrhage during cesarean delivery is uterine atony. The first man-
agement steps are uterine massage and pharmacological therapy, then surgical management.
Pharmacological therapy should proceed in a stepwise fashion from oxytocin (Pitocin®) 20 to 40
units per liter intravenously, to methylergonovine (Methergine®) 0.2 milligrams intramuscularly, to
F2a 15-methyl prostaglandin (Hemabate®). The initial dose of F2a 15-methyl prostaglandin is 0.25
milligrams. That dose can be repeated every 15 minutes to a maximum dose of 2.0 milligrams.
15-methyl-Prostaglandin F2α (hemabate) can be administered intramuscularly or directly into the
myometrium. (See Chapter J. Postpartum Urgencies). Misoprostol can be used as an alternative to
15-methyl-PGF2α. In an awake alert patient 400 mcg may be given subingual or buccal or 800 mcg
per rectum.
The surgical management of hemorrhage should also proceed in a step-wise fashion depending
on the patient’s hemodynamic status. The first step is bilateral O’Leary sutures of the uterine arter-
ies. (Slide 37) These zero or number one absorbable sutures are placed in the lateral aspect of
the uterus, just cephalad to the ureter. A second step to decrease uterine bleeding if the O’Leary
sutures are not sufficient is bilateral ligation of the uterine vessels just medial to the ovaries.
Next, uterine compression sutures are an effective method for reducing PPH and avoiding hyster-
ectomy. Limited follow-up of women who have had a uterine compression suture suggests that
there are no adverse effects on future pregnancy The B-Lynch suture envelops and compresses the
uterus, similar to the result achieved with manual uterine compression.37 In case reports and small
series, it has been highly successful in controlling uterine bleeding from atony when other methods
have failed.38
slide 35
slide 36
16 — — Chapter Q: Cesarean Delivery
Figure 1. Anterior uterine wall with B-Lynch stuture in place39
A large Mayo needle with #2 chromic catgut is used to enter and exit the uterine cavity anteriorly. The suture is looped over the fundus and then reenters the uterine cavity posteriorly as demonstrated in figures (a) and (b). The suture should be pulled very tight at this point. It is looped back over the fundus, and anchored by entering and exiting the anterior lateral loweruterine segment as shown in figure (a). The free ends of the suture are tied down securely to compress the uterus as shown in figure (c).
Bilateral ligation of the internal iliac arteries (hypogastric arteries) was often used in the past to con-
trol uterine hemorrhage by reducing pulse pressure of blood flowing to the uterus. The technique
is difficult, especially with a large uterus, a small transverse incision, a pelvis full of blood, and a
surgeon who rarely operates in the pelvic retroperitoneal space. A case series of nineteen patient
demonstrated that the majority (58 percent) still went on to hysterectomy despite bilateral internal
iliac ligation.89 For these reasons, uterine artery ligation and use of compressive uterine sutures has
largely replaced this procedure.40
If the hemorrhage continues after atony is resolved and the patient is hemodynamically stable, then
placement of one or more No. 30 French Foley catheter with a full 30 cc balloon through the cervix
into the uterine cavity may tamponade the bleeding. The Bakri tamponade balloon was specifically
designed for uterine tamponade to control postpartum bleeding.41 It is a silicone balloon with a
capacity of 500 mL of saline, and strength to withstand a maximum internal and external pressure of
300 mmHg (Figure 2). The balloon is filled until bleeding is controlled.
Figure 2. Bakri Balloon Catheter42
A) The Bakri balloon catheter is used for tem-porary control or reduction of postpartum hemorrhage when conservative management of uterine bleeding is warranted. It is easy to place and rapidly achieves tamponade within the uterine cavity, thereby potentially avoiding a hysterectomy. The tip allows drainage of accumulated blood.
B) Under ultrasound guidance, the balloon portion of the catheter is inserted into the uterus, making certain that the entire balloon is inserted past the cervical canal and internal ostium.
C) The device is intended for one-time use.
slide 38
slide 39
— Chapter Q: Cesarean Delivery — 17
These temporizing measures may allow time for correction of reversible conditions such as coagu-
lopathy or thrombocytopenia. An intravenous fluid bag can be attached to the catheter as it exits the
vagina to provide traction. Another modality to stop uterine bleeding is selective arterial emboliza-
tion. If these efforts fail, a hysterectomy may be necessary. In the setting of severe postpartum hem-
orrhage, obstetrical surgeons must balance the maternal risks of attempting to avoid hysterectomy
including massive transfusion and even mortality compared to the loss of desired fertility.
Lacerations Lacerations of the uterus are more common with malpresentations, macrosomia, or if the lower
uterine segment is very attenuated. If the lower uterine segment is very thin, then laceration can be
avoided if the uterine incision is made slightly higher than normal. Other common extensions are
into the broad ligament and vagina. To achieve a satisfactory repair, the full extent of the laceration
must be exposed and visualized. The first suture should be placed just beyond the apex of lacera-
tion. The remaining sutures can be placed in a locked or interrupted fashion. The surgeon should
visualize ureteral peristalsis throughout its course in the broad ligament to assure the uterine repair
did not injure the ureter.
Urinary Tract InjuryBladder injury is more common with a Pfannenstiel incision, repeat cesarean delivery, uterine rup-
ture, and cesarean hysterectomy. It is less common with sharp dissection between the lower uterine
segment and bladder than with blunt dissection. The ureter is most often injured during efforts to
control bleeding from lateral uterine lacerations.
Bladder injury is reported to occur in 0.28 percent (incidence in primary and repeat cesareans: 0.14
and 0.56 percent, respectively) of cesarean deliveries.43 In the same study, ureteral injury occurred
in 0.007 percent of all cesarean deliveries,43 compared to a rate of three percent in cesarean
hysterectomies.88
The dome of the bladder can be repaired with two-layers of two-zero absorbable suture. If the base
or trigone of the bladder is involved, then consultation is suggested. The ureters should be cannu-
lated to facilitate their identification during the repair. A urethral catheter should remain in place for
five to seven days after cystotomy.
Ureteral injury may go unrecognized, but if suspected, it is necessary to dissect the length of the
ureter to assure that ureteral peristalsis is present. Ureteral repair may require consultation from
urology, urogynecology or gynecological oncology surgeons. If the ureter is transected, a number
eight French ureteral catheter should be thread directly into the ureteral orifice. Another approach is
to cannulate the ureter through a cystotomy in the bladder dome. The cystotomy can be closed with
two layers of two-zero absorbable suture.
Gastrointestinal InjuryGastrointestinal injuries occur in 0.04 to 0.08 percent cesarean deliveries and are more common
when patients have adhesions from prior surgical procedures.44-45 The risk of bowel injury can be
minimized by limiting sharp dissection to transparent peritoneum, and lysis of adhesions to sharp
dissection with the scissors pointed away from the bowel. Full-thickness defects of less than one
centimeter are repaired in a double-layered transverse closure of a longitudinal laceration to avoid
slide 43
18 — — Chapter Q: Cesarean Delivery
bowel lumen narrowing. The mucosa is repaired with three-zero absorbable suture in an interrupted
fashion. The muscular and serosal layers are closed with a three-zero silk suture in an interrupted
fashion. Larger or complex lacerations may require consultation and assistance from a general
or colorectal surgeon. If fecal contamination of the operative field occurs, then copious irrigation
and broad-spectrum antibiotics with gram-negative aerobic and anaerobic coverage are needed.
Appropriate antibiotics include: Cefoxitin 1 to 2 grams IV every six hrs; Cefotetan 1 to 2 grams IV every
12 hrs + Gentamicin sulfate (Garamycin®) 1.5 mg/kg every eight hrs.46 If the colon is involved consider
adding metronidazole 0.5 to 1 grams IV or ampicillin-sulbactam 3 grams IV to the cephalosporin.46
Prophylactic wound drainage is rarely needed outside the settings of morbid obesity or a ‘wet’ wound.
Significant contamination may require secondary closure, especially in obese patients.
Anesthetic complicationsDespite the advances in anesthesia and increased use of regional anesthesia, the number of
deaths due to general anesthesia has not decreased.47 These deaths are frequently attributed to
the inability to intubate or ventilate the patient, and are more common when the patient is obese.
Other complications are aspiration, inadequate ventilation, respiratory failure, cardiac arrest, local
anesthetic toxicity, high spinal/epidural-related hypotension, over dosage, and spinal headache.
Although generally quite safe, these techniques are also associated with various untoward effects.
Side effects such as systemic local anesthetic toxicity or spinal headache are caused by technical
factors and/or dosing, such as inadvertent intravenous injection or unrecognized dural puncture.
Spinal hematoma is a rare complication, and is more likely in patients receiving anticoagulants.
Meticulous attention to proper technique reduces the risk of these complications. Should they
occur, prompt treatment is indicated.
Other common side effects are caused by known pharmacological effects of the analgesic medica-
tions, such as hypotension, pruritus, nausea and vomiting and respiratory depression. Hypotension
may be treated by administering a vasopressor. Opioid-induced side effects are optimally managed
by administering small doses of an opioid antagonist.
A variety of other side effects have been attributed to regional analgesic techniques, such as
long-term backache, effects on the progress and outcome of labor and effects on breastfeeding
success. Although an association between regional analgesia and these side effects may exist, a
cause-and-effect relationship has not been established. The risk of potential unwanted effects must
be weighed against the unparalleled pain relief these techniques provide.
Studies have shown that women who have regional anesthesia have decreased blood loss and less
of a post-operative drop in their hematocrit compared to those who have general anesthesia.48
POST-OPERATIVE CAREThe care of the post-operative cesarean delivery patient is similar to that provided for any major
abdominal surgery. (Table 7)
The wound dressing should be removed in 24 hours and the wound monitored daily. The surgical
clips can be removed in three days and tape strips placed for transverse skin incisions. With vertical
incisions, clips are removed and tape strips placed at five to seven days. Breast-feeding should be
— Chapter Q: Cesarean Delivery — 19
encouraged for all women. The post-operative hemoglobin will determine iron replacement. Discharge
can usually be accomplished in two to four days with a gradual return to full activity based on patient
comfort. Fertility planning should be discussed prior to discharge and again at the six-week visit.
Table 7. Postoperative Orders
1. Vital signs and fundal status every hour X four, every four hours X 24, then every eight hours.
2. Massage uterus per schedule above; report extra lochia.
3. Intake and output every four hours X 24.
4. Activity ad lib, encourage ambulation TID.
5. Cough, deep breathing, and incentive spirometry every one hour when awake.
6. Foley to closed drainage, discontinue catheter first post-operative morning, or when ambulating well.
7. Diet as tolerated after nausea resolved.
8. D5 lactated ringers with 20 units of oxytocin (Pitocin®) / liter at 125 cc/hr times two bags, then D5 lactated ringers @ 125 cc/hr. Convert to heparin lock when tolerating oral well.
9. Morphine sulfate two to eight mg intravenously every two hours as needed for pain.
10. Droperidol (Inapsine®) 1.25 to 5.0 mg every four hours intravenously, PRN nausea (or promethazine (Phenergan®) 25 to 50 mg every four hours intramuscularly PRN).
11. Oxycodone and acetaminophen (Percocet®) one to two every three to four hours, PRN, after tolerating oral intake.
12. Lab: first post-operative AM — hemoglobin/hematocrit.
13. Administer Rhogam® if indicated by infant cord blood Rh status.
14. Administer rubella, hepatitis, and Dtap vaccines at discharge if indicated.
Post-Operative Patient InstructionsPost-cesarean delivery patient instructions are similar to any major GYN or abdominal surgery.
• Call the office for any problems, including increased abdominal pain, fever, or vaginal discharge.
• The abdominal wound should be kept dry and is best treated with minimal dressing. The area
can be cleansed with warm water and mild soap. The patient should notify their provider if
they notice redness or increased warmth, drainage, feel fluid under the skin, or for temperature
greater than 100.5º F, or 38º C.
• If the patient has unanswered questions after the cesarean, then the patient should discuss them
with their physician or case manager. An unhurried conversation with their doctor, when they are
feeling well, will go a long way toward resolving questions the patient may have.
• Patients should be educated about the risks of vertical uterine incisions versus low-transverse inci-
sions for future pregnancies. In our increasingly mobile society, it is reasonable to provide the patient
with a copy of her operative report for presentation to her clinician during a subsequent pregnancy.
Recommendations for activity after obstetric and gynecologic procedures remain based on tradi-
tion and anecdote. The available data do not support many of the recommendations currently pro-
vided.49 Restrictions on lifting and climbing stairs should likely be abandoned. Guidance on driving
should focus on the concern regarding cognitive function and analgesics rather than concerns of
wound separation/dehiscence. Given the impact of these recommendations on daily life events,
consistent, evidence-based advice on when and how women can safely resume exercise, driving,
working, and sexual intercourse is critical. (Table 8)
slides 40-41
slides 42-43
20 — — Chapter Q: Cesarean Delivery
Table 8. Evidence Supporting Advice
Advice Evidence Our Recommendations Future ResearchLifting Lifting increases
intraabdominal pres-sure much less than Valsalva, forceful coughing, or rising from supine to erect position
• Patients should continue lifting patterns as before surgery
• Patients need an adequate post-op analagesic regimen
• Pre and post recommendations should be consistent
• Prospective cohort study of patients encouraged to resume regular exercise program
• Trial in which women are randomly assigned to lift weights lighter than before surgery or lift the same amount of weights
Climbing stairs
Climbing stairs increases intraabdomi-nal pressure much less than Valsalva, forceful coughing or rising from supine to erect position
• Patients should continue climbing stairs as before surgery
• Patients need an adequate postop analgesic regimen
• Pre and post recommendations should be consistent
• Prospective cohort study of patients encouraged to resume regular exercise program, including climbing stairs
Driving No retrospective or prospective evidence
• Patients need an appropriate postop analgesic regimen that does not cause a clouded senso-rium when driving
• Patients may resume driving when comfortable with hand and foot movements required for driving
• Pre and postop recommendations should be consistent
• Prospective cohort study of women encouraged to resume normal activities, including driving
Exercise Limited retrospec-tive and prospective evidence. Forceful coughing increases intraabdominal pres-sure as much as jump-ing jacks
• Patients need an appropriate postop analgesic regimen
• Patients may resume preop exer-cise level
• Exercise program may need to be tailored for postpartum women
• Pre and postop recommendations should be consistent
• Prospective interventional studies to encourage women to resume exercise programs, as well as build strength and cardiovascular health
Vaginal intercourse
No consistent retro-spective evidence; no prospective evidence
• Women and their partners should make the decision to resume intercourse mutually
• Women should use vaginal lubri-cants and sexual positions permit-ting the woman to control the depth of vaginal penetration
• Women should use appropriate contraception after childbirth
• Pre and postop recommendations should be consistent
• Prospective interventional studies aimed to help women resume sexual intimacy after gynecologic surgery; such studies should capture data on incidence of vaginal valt dehiscence and its associated factors
Returning to work
No consistent pro-spective or retrospec-tive evidence
• Women should be encouraged to return to work relatively soon postop
• Consider graded return to work• Pre and postop recommendations
should be consistent
• Prospective studies evaluat-ing the optimal strategies to permit women to return to effective work
Reprinted from Obstet Gynecol, 2009 Oct;114(4):892-900, Minig L, Trimble EL, Sarsotti C, Sebastiani MM, Spong CY, Building the evidence base for postoperative and postpartum advice, with permission from Wolters Kluwer Health 2011.
— Chapter Q: Cesarean Delivery — 21
EARLY POST-OPERATIVE COMPLICATIONSThe most common early complications after cesarean delivery are infectious. The rate of infection with-
out prophylactic antibiotic approaches 85 percent, while the infection rate with prophylactic antibiotics
is only about five percent. Hence, routine antibiotic therapy is more than “prophylactic.” A single dose
of a first generation cephalosporin or ampicillin is as effective as other regimens, including multiple
doses or lavage techniques.8-9 Atelectasis is a common source of fever and can lead to pneumonitis.
Septic shock, pelvic abscess, and septic thrombophlebitis occur in less than two percent of cases.
Endomyometritis Endomyometritis is a clinical diagnosis that presents with uterine or parametrial tenderness, fever
(two postoperative temperatures over 38º C beyond 24 hours), and leukocytosis. The leukocyte
count is normally elevated in labor and the early puerperium, averaging 14,000 to 16,000 per mil-
limeter and may not help in distinguishing an infectious etiology. Cultures of the lochia are often
misleading. Blood cultures are frequently negative. Ninety percent of cases will resolve within 72
hours with broad-spectrum intravenous antibiotics. A small percentage of patients will develop sep-
tic thrombophlebitis, parametrial phlegmon, pelvic abscess, and peritonitis.
Wound Separation/InfectionWound separation or opening is a common surgical complication after cesarean delivery, occurring
in approximately five percent of cases. Of those wounds that open, nearly two-thirds are infected.50
Wound infection presents with erythema and tenderness, and may develop purulence and fever.
Wound infection is a clinical diagnosis with laboratory data serving as an adjunct. The leukocytosis
is variable and wound cultures are often misleading. Ultrasound of the abdominal wall may be help-
ful to localize an abscess. Treatment includes broad-spectrum antibiotics and vigorous wound care.
The wound may need to be probed, opened, irrigated, and packed, and necrotic tissue debrided.
The patient and caregiver should be instructed about ongoing home care. The decision about
delayed secondary closure versus healing by secondary intention will be influenced by the size of
the wound and the logistics of follow-up care.
Fascial dehiscence occurs in approximately six percent of open wounds.50 Fascial dehiscence
presents with copious discharge followed by protrusion of bowel through the surgical wound. If
this occurs, the bowel should be covered with a moist sterile gauze pad and consultation obtained
immediately. The wound should be explored, cleansed, debrided, and closed with retention sutures
or a mass closure (e.g., Smead-Jones closure), using long-term absorbable suture.
Urinary Tract InfectionUrinary tract infections are often associated with use of an indwelling urethral catheter. Treatment
should be initiated with broad-spectrum antibiotics, and subsequent antibiotic therapy based on
urine culture and sensitivity results.
Gastrointestinal ComplicationsAn ileus presents with abdominal distention, nausea, vomiting, and failure to pass flatus. Physical
exam may reveal the absence of bowel sounds. Radiographic studies show distended loops of
small and large bowel, with gas usually present in the colon. Treatment involves withholding oral
intake, awaiting the return of bowel function, and providing adequate fluids and electrolytes.
slide 44
22 — — Chapter Q: Cesarean Delivery
In contrast, obstruction has high-pitched bowel sounds and peristaltic rushes. Radiographic studies
show single or multiple loops of distended bowel, usually in the small bowel, with air fluid levels. The
patient may need nasogastric suctioning, or a duodenal/jejunal tube. Surgical consultation and pos-
sible lysis of adhesions may be needed if an obstruction persists.
Thromboembolic ComplicationsDeep venous thrombosis (DVT) is three to five times more common after cesarean delivery than vaginal
delivery. DVT can progress to pulmonary embolus if untreated. DVT typically presents with leg tender-
ness, swelling, a palpable cord, or a positive Lowenberg test. (See Chapter B. Medical Complications)
The American College of Chest Physicians practice guidelines recommend early mobilization in
postpartum women with no risk factors for DVT other than the postpartum state and the operative
delivery.51 For women with at least one additional risk factor, they suggest pharmacologic thrombo-
prophylaxis (prophylactic low molecular weight heparin or unfractionated heparin) or mechanical
prophylaxis while the patient is in the hospital. . For women with multiple risk factors for thrombo-
embolism, they suggest pharmacologic thromboprophylaxis combined with graduated compression
stocking and/or intermittent pneumatic compression. Marik and Plante (see table 9) developed a
risk stratification approach to VTE prophylaxis.52
Table 9. Risk Assessment for Thromboembolism in Patients Who Undergo Cesarean Section*
Low Risk: early ambulation
– Cesarean delivery for uncomplicated pregnancy with no other risk factors
Moderate risk: low-molecular-weight heparin or compression stockings
– Age > 35 yr
– Obesity (BMI > 30)
– Parity > 3
– Gross varicose veins
– Current infection
– Preeclampsia
– Immobility for > four days before operation
– Major current illness
– Emergency cesarean section during labor
High risk: low-molecular-weight heparin and compression stockings
– Presence of more than two risk factors from the moderate risk section
– Cesarean hysterectomy
– Previous deep-vein thrombosis or known thrombophilia
*BMI denotes body-mass index (the weight in kilograms divided by the square of the height in meters).
— Chapter Q: Cesarean Delivery — 23
Septic Thrombophlebitis Septic thrombophlebitis is a diagnosis of exclusion. Persistent and unexplained fever is often the
only symptom of septic thrombophlebitis, though some patients complain of pelvic pain. Physical
examination, ultrasound, and computerized tomography are frequently negative. Continued fever
without a known origin despite several days of antibiotic therapy suggests septic thrombophlebitis.
Defervescence on heparin therapy provides effective treatment and confirms the diagnosis.
DELAYED POST-OPERATIVE COMPLICATIONSUterine Dehiscence and/or Rupture Dehiscence and rupture of a uterine scar are uncommon complications that are diagnosed during a sub-
sequent pregnancy. They are discussed in detail in the section on Trial of Labor after Cesarean below.
Placenta Accreta There is a significant increased risk of placenta previa, placenta accreta, placenta previa with
accreta, and the need for gravid hysterectomy after a woman’s second cesarean delivery.53
One in four patients who undergoes repeat cesarean delivery because of placenta previa will
require cesarean hysterectomy for hemorrhage caused by placenta accreta. This complication
increases with the number of prior uterine incisions.54 In focal placenta accreta, the placental bed
can be curetted and over sewn with interrupted sutures placed around the area of hemorrhage. If
not successful, then complete hysterectomy may be necessary, because supracervical hysterec-
tomy may not control the hemorrhage.
Repeat Cesarean Delivery A major complication of cesarean delivery is that nearly two thirds of patients will undergo cesarean
delivery with subsequent pregnancies. Repeated surgeries may also involve adhesions and subfer-
tility, chronic pain syndromes and keloid formation.
Cesarean Hysterectomy Indications for cesarean hysterectomy are uterine hemorrhage unresponsive to treatment, uterine
laceration that would result in an unstable repair, placenta accreta, laceration of major pelvic ves-
sels, large myomas, and advanced cervical dysplasia or carcinoma. Complications of cesarean
hysterectomy are more common during emergent procedures and include increased blood loss and
anesthesia time, plus infection, blood transfusion, and unanticipated sterility.
CONTROVERSIESElectronic Fetal Monitoring The widespread use of electronic fetal monitoring (EFM) and the increased rate of cesarean delivery
in response to fetal heart patterns detected with EFM have neither decreased acidosis-related
newborn morbidity, nor decreased the incidence of cerebral palsy. (See Chapter E. Intrapartum
Fetal Surveillance)
Breech Presentation The American College of Obstetricians and Gynecologists recommends that the decision regarding
mode of delivery should depend on the experience of the health care provider Cesarean delivery will
be the preferred mode for most physicians because of the diminishing expertise in vaginal breech
delivery.55 Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-
slide 45
slide 46
24 — — Chapter Q: Cesarean Delivery
specific protocol guidelines56 for both eligibility and labor management. Before a vaginal breech
delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or
short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned,57 and
the patient’s informed consent should be documented.55
Women with a breech presentation at 37 weeks should be encouraged to undergo external
cephalic version if they do not have a contraindication. When VBAC or vaginal breech delivery are
not offered by either the patient’s provider or planned hospital, referral to a provider and/or facility
that does offer these should be investigated.58 Planned cesarean delivery compared with planned
vaginal birth reduced perinatal or neonatal death or serious neonatal morbidity, at the expense of
somewhat increased maternal morbidity.59 (See Chapter G. Malpresentations)
Incidental Procedures Some clinicians choose to perform a cesarean delivery on patients near term if the patient has
another indication for surgery, e.g., desires sterilization. Several simple methods that result in tubal
occlusion are available. Performance of an elective cesarean delivery because of the second sur-
gical procedure should be discouraged because of the increased morbidity and hospital stay.
The surgeon’s primary responsibility is safe operative delivery, even when pathology is found.
Removal of adnexal abnormalities should be reserved for obvious malignancy, or lesions sus-
ceptible to torsion. Most leiomyomas regress after pregnancy and are highly vascular, hence
removal should not be attempted unless an accessible pedicle and torsion is anticipated. Such
lesions should be cross-clamped and Heaney transfixion ligated with an absorbable suture. A
woman’s lifetime risk for acute appendicitis is approximately 10 percent at age 17, but falls to
only 3.5 percent by age 37. Thus, routine elective removal of the appendix at the time of cesar-
ean delivery is not indicated.
Macrosomia Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery
may be considered for suspected fetal macrosomia with estimated fetal weights greater than
5,000 g in women without diabetes and greater than 4,500 g in women with diabetes.60 A
review of the available literature on the sonographic detection of macrosomia (> 4000 g) in
general obstetrical populations reported widely varying results: sensitivity 12 to 75 percent,
specificity 68 to 99 percent, and posttest probability after a positive test 17 to 79 percent;
results for populations with a high prevalence of macrosomia were at the upper end of these
ranges.61 The diagnosis of macrosomia defined as > 4500 was even less accurate, and there
were no data on the ability to identify fetuses > 5000 g. Hence 3,695 cesarean deliveries would
have to be performed at an additional cost of $8.7 million, to prevent one permanent brachial
plexus injury in fetuses over 4,500 gram in mothers without diabetes.62 Most brachial plexus
injuries resolve spontaneously, and can occur in fetuses weighing less than 4,000 grams born
by cesarean delivery. The results of the single randomized controlled trial comparing elective
delivery with expectant management at term in pregnant women with insulin-requiring diabetes
show that induction of labor reduces the risk of macrosomia.63 Induction of labor for suspected
fetal macrosomia in non-diabetic women has not been shown to alter the risk of maternal or
neonatal morbidity.64
— Chapter Q: Cesarean Delivery — 25
slides 47-49
slides 50-52
Litigation Concerns over liability risk have a major impact on the willingness of physicians and health care
institutions to offer trial of labor.6 These concerns derive from the perception that catastrophic
events associated with trial of labor could lead to compensable claims with large verdicts or settle-
ments for fetal/maternal injury—regardless of the adequacy of informed consent. Clearly, these
medical malpractice issues affect practice patterns among health care providers and they played a
role in the genesis of the College’s 1999 “immediately available” guideline.
Studies have attempted to model the impact of tort reform on primary and repeat cesarean deliv-
ery rates and have shown that modest improvements in the medical-legal climate may result in
increases in VBAC and reductions in cesarean deliveries.6 These analyses suggest that both caps
on noneconomic damages and reductions in physician malpractice premiums would result in fewer
cesarean deliveries.
Many health care providers incorrectly assume that performing a cesarean delivery helps avoid mal-
practice litigation. Performance of a cesarean offers no protection against allegations of malpractice if
a less-than perfect infant is born. The plaintiff’s legal team may shift to other issues, such as the cesar-
ean delivery not being performed sooner, or a perceived lack of antenatal testing or prenatal care.
PERIMORTEM HYSTEROTOMY (CESAREAN DELIVERY)Cesarean delivery has come full circle from its ancient origins as a postmortem procedure to bury
mother and infant separately, to the current recommendation that all appropriately skilled physicians
should be able to perform a perimortem cesarean delivery that could save two lives.65 The American
Heart Association has recommended perimortem cesarean delivery in pregnant women who have not
responded to resuscitative efforts since the 1990s.66 Uterine evacuation can increase cardiac output by
25 percent by relief of aortocaval compression. If promptly performed, perimortem cesarean delivery
improves infant and maternal survival. The best survival rates are obtained when perimortem cesarean
delivery is performed within five minutes of ineffective maternal circulation. It is still worthwhile to pursue
delivery after five minutes, however, because fetal mortality is 100 percent if no action is taken. It is not
necessary to obtain consent from family members before performing the procedure. (See Chapter K.
Maternal Resuscitation).
Emergency hysterotomy is indicated when:
• Personnel with appropriate skill and equipment to perform the procedure are involved,
• The mother fails to respond with a return of spontaneous circulation within four minutes,
• Singleton gestation of 20 weeks or greater, and
• Appropriate facilities and personnel are available to care for the mother and infant after
the procedure.
TRIAL OF LABOR AFTER CESAREAN (TOLAC) Counseling regarding cesarean delivery should occur during the prenatal care of all women. Most
nulliparous women have a strong preference for spontaneous vaginal delivery and will be interested in
ways in which they can decrease the likelihood of requiring a cesarean in labor.58
26 — — Chapter Q: Cesarean Delivery
The decision by a pregnant woman to attempt a TOLAC or a planned repeat cesarean delivery involves
a balancing of maternal and neonatal risks for each woman, as well as personal preference. The rate
of perinatal mortality associated with TOLAC is similar to the perinatal mortality rate for infants born to
nulliparous women in labor, 1.3/1000 births compared to 0.5/1000 births in women choosing repeat
cesarean delivery.67
During the informed consent process at least three basic issues need to be addressed:
• What is the patient’s plan for future family size?
• What is the chance of a successful vaginal birth after cesarean?
• What are the safety concerns?
FUTURE FAMILY SIZEAlthough there is no difference between planned cesarean delivery and planned vaginal delivery in risk
of peripartum hysterectomy in a woman’s first delivery, there is a significant increased risk of placenta
previa, placenta accreta, placenta previa with accreta, and the need for gravid hysterectomy after a
woman’s second cesarean delivery.53 This emphasizes the need to consider the mother’s total number
of planned or expected pregnancies if cesarean delivery on maternal request is discussed during her
first pregnancy, realizing that many pregnancies are unplanned.69 These are also factors that may be
influenced by parity and planned family size. Uterine scars put women at increased risk for uterine
rupture in subsequent pregnancies.67, 70
For those considering larger families, VBAC may avoid potential future maternal consequences of
multiple cesarean deliveries69 such as hysterectomy, bowel or bladder injury, transfusion, infection,53, 71
and abnormal placentation such as placenta previa and placenta accrete.53-54
CHANCE FOR SUCCESSFUL VAGINAL BIRTHMost women with one previous cesarean delivery with a low-transverse incision are candidates for and
should be counseled about VBAC and offered TOLAC.69
Approximately 75 percent of women who attempt TOLAC will be successful; this rate varies up or down
depending upon the clinical situation that led to the first cesarean birth.6 VBAC is highest in women
with a previous successful TOLAC, previous vaginal delivery, previous cesarean delivery for nonvertex
presentation, and women with spontaneous onset of labor. (see Figure 1)
The studies of women with twin gestations who attempt VBAC have consistently demonstrated that their
outcomes are similar to those of women with singleton gestations who attempt VBAC with regard to
likelihood of success and risk of uterine rupture or maternal or perinatal morbidity complications.72-73
Women with one previous low transverse cesarean delivery, who are otherwise appropriate candidates
for twin vaginal delivery, may be considered candidates for TOLAC.69
— Chapter Q: Cesarean Delivery — 27
slides 53-55Figure 1. Factors that impact the success of a trial of labor after cesarean delivery
Decreased success (< 60 percent)– Two or more prior cesarean deliveries without a vaginal delivery
– Cesarean delivery for failure to descend in second stage
– Labor induction required
– Infant 4000 g or more
– Body mass index (BMI) greater than 40 kg/m2
– Maternal age older than 35 years
Neutral success (65 percent to 75 percent)– Gestational age older than 40 weeks
– Prior cesarean delivery for nonreassuring fetal monitoring
– Unknown scar
– Twins (limited data)
– Labor augmentation
– Two prior cesarean deliveries with history of vaginal birth (limited data)
– Cesarean delivery for failure to progress in first stage of labor
– BMI 25 to 40 kg/m2
Increased success (> 75 percent)– Prior successful vaginal birth
– BMI 25 kg/m2 or less
– Prior cesarean delivery for breech presentation
– Spontaneous labor with ripe cervix by Bishop score
– Maternal age younger than 35 years
Percentages are estimates of the influence of a single factor’s influence on the success of a trial of
labor. Because patients rarely present with only one of these issues, providers must try to balance
the impact of a series of influences to individually guide patients in their decision to attempt trial of
labor as the delivery plan. Note that even in the presence of factors that have a negative impact,
most women attempting a trial of labor after cesarean will be successful.
Although there is no universally agreed on discriminatory point,69 evidence suggests that women
with at least a 60 to 70 percent chance of VBAC have equal or less maternal morbidity when they
undergo TOLAC than women undergoing elective repeat cesarean delivery.74–75 Conversely, women
who have a lower than 60 percent probability of VBAC have a greater chance of morbidity than
women undergoing repeat cesarean delivery. Similarly, because neonatal morbidity is higher in the
setting of a failed TOLAC than in VBAC, women with higher chances of achieving VBAC have lower
risks of neonatal morbidity. One study demonstrated that composite neonatal morbidity is similar
between TOLAC and elective repeat cesarean delivery for the women with the greatest probability of
achieving VBAC.75
SAFETY CONCERNSWomen with previous cesarean delivery have two options for delivery during subsequent
pregnancies; they may have an elective repeat cesarean delivery or they may undergo a trial
of labor after cesarean (TOLAC). Sixty to 80 percent of women with previous cesarean delivery
28 — — Chapter Q: Cesarean Delivery
can experience a successful vaginal delivery with a prior cesarean delivery.67 The benefit of this
is decreased maternal risk associated with vaginal delivery (decreased blood loss and risk of
transfusion, decreased risk of thromboembolism, and decreased risk of infection) and a quicker
recovery period with decreased length of hospitalization. (See Appendix 1)
Planned elective repeat caesarean delivery and planned vaginal birth after cesarean delivery for
women with a prior caesarean birth are both associated with benefits and harms. The two major
risks of TOLAC are uterine dehiscence and/or rupture. Due to the risk of uterine rupture fetal death
has been shown to increase with TOLAC versus repeat elective cesarean delivery. Evidence for the
risks and benefits of TOALC vs repeat cesarean are predominantly from retrospective cohort studies
due to the inability to conduct randomized controlled trials.76
Uterine Dehiscence and/or RuptureDehiscence and rupture of a uterine scar are uncommon complications that are diagnosed during
a subsequent pregnancy. The overall rate of uterine rupture during a subsequent TOLAC is 0.7 per-
cent.70, 77 (See Figure 2)
Symptomatic uterine rupture occurs in 0 to 7.8 per 1000 TOLACs (pooled weighted mean 3.16 per
1000 TOLACs).67, 70 On average, the incremental risk of rupture with TOLAC compared with elective
repeat cesarean delivery (ERCD) is 2.7 per 1000.
The term uterine dehiscence is commonly applied to asymptomatic scar separation that does not
penetrate the serosa and does not produce hemorrhage. Dehiscence occurs in 0 to 19 per 1000
TOLACs (mean weighted average 12.6 per 1000 TOLACs). This rate is comparable to that in women
undergoing ERCD.67 Dehiscence presents as a “serosal window” and is often discovered unexpect-
edly during a repeat cesarean delivery. (Box 2) Rupture of lower segment scars usually occurs dur-
ing labor, but may occur antepartum, particularly with classical uterine scars.78
RUPTUREIn contrast to dehiscence, uterine rupture is a through-and-through scar separation that is clinically
symptomatic and requires surgical intervention. Uterine rupture occurs in about 0.7 percent of
women with a prior cesarean delivery.70, 77
Fetal bradycardia is the most common and characteristic clinical manifestation of uterine rupture,
occurring in 33 to 70 percent of symptomatic cases.79 Variable or late decelerations may precede
the bradycardia, but there is no fetal heart rate pattern pathognomonic of rupture. Perinatal mortal-
ity/morbidity is higher in fetuses that experience complete extrusion into the maternal abdomen
than in those who are not extruded.80
Maternal manifestations are variable. In women with known uterine scarring or trauma, uterine rup-
ture should always be strongly considered if constant abdominal pain and signs of intraabdominal
hemorrhage are present. Vaginal bleeding is not a cardinal symptom, as it may be modest, despite
major intraabdominal hemorrhage. Other clinical manifestations include maternal tachycardia, hypo-
tension ranging from subtle to severe (hypovolemic shock), cessation of uterine contractions, loss of
station of the fetal presenting part, uterine tenderness, and change in uterine shape.
— Chapter Q: Cesarean Delivery — 29
Postpartum, uterine rupture is characterized by pain and persistent vaginal bleeding despite use of
uterotonic agents. Hematuria may occur if the rupture extends into the bladder.
Treatment of symptomatic uterine rupture is largely dependent on the patient’s hemodynamic status
and desire for future fertility. In some cases, a layered closure of the myometrium with absorbable
suture will suffice, though hysterectomy may be necessary.
PREVIOUS UTERINE INCISIONThe preponderance of evidence suggests that most women with one previous cesarean delivery with a
low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.
A 2006 study with sufficient size to control for confounding variables found no increased risk of uterine
rupture (0.9 percent versus 0.7 percent) in women with one versus multiple prior cesarean deliveries.81
Additionally, the chance of achieving VBAC appears to be similar for women with one or more than
one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low
transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combi-
nation of other factors that affect their probability of achieving a successful VBAC.69
Those at high risk for complications (e.g., those with previous classical or T-incision, prior uterine
rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise
contraindicated (e.g., those with placenta previa) are not generally candidates for planned TOLAC.69
INDUCTION LABORInduction of labor for maternal or fetal indications remains an option in women undergoing TOLAC.69
Studies of specific prostaglandins are limited in size, but indicate that rupture risk may vary among
these agents. Given the lack of compelling data suggesting increased risk with mechanical dilation
and transcervical catheters, such interventions may be an option for TOLAC candidates with an unfa-
vorable cervix.69
Evidence from small studies show that the use of misoprostol (prostaglandin E1) in women who have
had cesarean deliveries is associated with an increased risk of uterine rupture.82 Therefore, misopro-
stol should not be used for third trimester cervical ripening or labor induction in patients who have
had a cesarean delivery or major uterine surgery.69
REGIONAL ANALGESIAEpidural analgesia for labor may be used as part of TOLAC, and adequate pain relief may encour-
age more women to choose TOLAC.69, 83 No high quality evidence suggests that epidural analgesia
is a causal risk factor for an unsuccessful TOLAC.84 In addition, effective regional analgesia should
not be expected to mask signs and symptoms of uterine rupture, particularly because the most com-
mon sign of rupture is fetal heart tracing abnormalities.
EXTERNAL CEPHALIC VERSIONLimited data regarding external cephalic version for breech presentation in a woman with a prior
uterine incision suggest that external cephalic version is not contraindicated if a woman is at low
risk of adverse maternal or neonatal outcomes from external cephalic version and TOLAC.85 The
chances of successful external version have been reported to be similar in women with and without
a prior cesarean delivery.69
30 — — Chapter Q: Cesarean Delivery
slides 56-58
UNKNOWN TYPE OF PREVIOUS UTERINE INCISIONThe type of uterine incision performed at the time of a prior cesarean delivery cannot be confirmed
in some patients. Although some have questioned the safety of offering VBAC under these circum-
stances, two case series, both from large tertiary care facilities, reported rates of VBAC success and
uterine rupture similar to those from other contemporaneous studies of women with documented
previous low transverse uterine incisions.86 No significant association was found with the presence
of an unknown scar when evaluating risk factors for uterine rupture. The absence of an association
may result from the fact that most cesarean incisions are low transverse, and the uterine scar type can
often be inferred based on the indication for the prior cesarean delivery. Therefore, TOLAC is not con-
traindicated for women with one previous cesarean delivery with an unknown uterine scar type unless
there is a high clinical suspicion of a previous classical uterine incision.69
Figure 2. Factors influencing risk for uterine rupture
Decreased success (< one percent)– Prior vaginal delivery
– Low uterine segment incision from prior cesarean
– Preterm delivery
– Two-layer closure of uterine incision
Neutral success (one to two percent)– Induction of labor with good Bishop score with oxytocin
– One-layer uterine closure
– Gestational age of more than 40 weeks
– Low vertical uterine incision (limited data; could be increased to up to five percent)
– Unknown uterine scar without high risk for prior classical incision
Increased success (less than two to four percent)– Unknown scar in the setting of high risk for prior classical incision
(e.g., preterm abnormal lie or term transverse lie)
– Classical or T uterine incision (four to nine percent)
– Prior, myomectomy, cornual resection, or other full-thickness uterine surgery
– Prior uterine rupture
– Morbid obesity (BMI > 40 kg/m2)
– Two or more prior uterine incisions without vaginal delivery
– Induction of labor with poor Bishop score with prostaglandin agent or oxytocin
Percentages are estimates of the influence of a single factor’s influence on the likelihood of uterine
rupture. Because patients rarely present with only one of these factors and evidence is limited on
the additivity of multiple factors, physicians or midwives must try to assess the impact of a series of
influences to provide individualized guidance to a patient during prenatal care.
LEVEL OF CAREAfter consideration of the NIH Consensus Development Conference on Vaginal Birth After
Cesarean data ACOG stated that a trial of labor after previous cesarean delivery should be under-
taken at facilities capable of emergency deliveries.69
— Chapter Q: Cesarean Delivery — 31
“Because of the risks associated with TOLAC and that uterine rupture and other complications may be
unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately
available to provide emergency care. When resources for immediate cesarean delivery are not available,
the College recommends that health care providers and patients considering TOLAC discuss the hospi-
tal’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for
patient autonomy supports that patients should be allowed to accept increased levels of risk, however,
patients should be clearly informed of such potential increase in risk and management alternatives.”69
Furthermore ACOG stated that after counseling, the ultimate decision to undergo TOLAC or a
repeat cesarean delivery should be made by the patient in consultation with her health care pro-
vider.69 The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should
be discussed. Documentation of counseling and the management plan should be included in the
medical record.
The Northern New England Perinatal Quality Improvement Network (NNEPQIN) VBAC Guidelines
has offered a three tiered risk based system with management suggestions87 (Table 10). This system
would need to be modified for individual facilities, level of resources, and as new data emerges.
Table 10.
Patient Classification
Condition/Complications Management Approach
Low risk - One prior low transverse cesarean delivery
- Spontaneous onset labor- No need for augmentation- No repetitive FHR abnormalities- Patients with a prior successful VBAC are especially low risk. However, their risk status escalates the same as other low risk patients.
- No additional interventions other than those listed above.
- Cesarean delivery provider may have other acute patient care responsibilities.
Medium risk - Induction of labor- Pitocin augmentation- Two or more prior low transverse cesarean deliveries
- < 18 months between prior cesarean delivery and current delivery.
- Cesarean delivery provider in the hospital dur-ing the active phase of labor. Cesarean delivery provider may have other acute patient care responsibilities.
- An open and staffed operating room is available or there is a plan in place if immediate delivery is required. This may be a room where there is adequate lighting, instruments, and general anesthesia can be administered if needed.
- An anesthesia provider is present in the hospital during the active phase of labor.
- Anesthesia staff may have other acute patient care responsibilities.
- There is an established back up protocol for anesthesia services during busy times.
High risk - Repetitive non-reassuring FHR abnor-malities not responsive to clinical intervention.
- Bleeding suggestive of abruption- Two hours without cervical change in the active phase despite adequate labor
- The cesarean delivery provider is present in the hospital and does not have other acute patient care responsibilities
- Anesthesia staff is present and does not have other acute patient care responsibilities.
- An open and staffed operating room is available.
32 — — Chapter Q: Cesarean Delivery
slide 59
SUMMARYCesarean delivery is the most common operative procedure in the US and has accounted for nearly
one third of all deliveries. Cesarean delivery can involve significant morbidity and mortality, both of
which can be minimized by thoughtful patient selection, pre-operative, intra-operative and post-oper-
ative care. All maternity care providers should be familiar with the diagnosis and management or
post-cesarean complications. Efforts to lower the primary cesarean rate and increase access to trial
of labor after cesarean are of public health importance due to the increased morbidity and mortality
of repeat cesarean delivery.
The application of evidence-based practice to cesarean delivery and support for patient safety in the
operating room and postpartum settings can decrease operative morbidity.
SUMMARY OF TABLE RECOMMENDATIONSCategory AThe Joel-Cohen–based techniques have advantages over Pfannenstiel and traditional cesarean
techniques in relation to short-term outcomes. There is no evidence in relation to long-term outcomes.14
No preoperative hair removal; or clipping or depilatory creams on the day of surgery or the preceding
day (no shaving).14
No specific antiseptic for preoperative bathing.14
Suture closure of subcutaneous fat results in a decreased risk of wound disruption with fat thickness
greater than 2 cm.29-30
Subcuticular sutures, interrupted sutures, staples, or tissue adhesive skin closure are acceptable.31-34
No withholding of oral fluids after surgery.35
Category BAntibiotic prophylaxis with a single dose of ampicillin or a first-generation cephalosporin9 prior to
skin incision at cesarean delivery.10-11
Double gloving is advised in areas with high rates of blood-borne infections to achieve fewer perfora-
tions in inner glove and prevent needle stick injuries.14
Transverse lower abdominal wall opening and uterine opening using Joel-Cohen–based methods.15
Bladder peritoneum may be reflected downward or not.17
Spontaneous placental removal with cord traction reduces blood loss.22
Either intraabdominal or extraabdominal repair of the uterus are acceptable.24
Nonclosure of both peritoneal layers.28
No routine drainage of the subcutaneous tissues.36
Most women with one previous cesarean delivery with a low-transverse incision are candidates for
and should be counseled about VBAC and offered TOLAC.69, 77
Epidural analgesia for labor may be used as part of TOLAC.69, 84
Women with two previous low transverse cesarean deliveries may be considered candidates for
TOLAC.69, 81
Women with one low transverse incision, who are otherwise appropriate candidates for twin vaginal
delivery, may be considered candidates for TOLAC.69, 72, 73
— Chapter Q: Cesarean Delivery — 33
External cephalic version for breech presentation is not contraindicated in women with a prior low
transverse uterine incision who are at low risk for adverse maternal or neonatal outcomes from
external cephalic version and TOLAC.69, 85
TOLAC is not contraindicated for women with previous cesarean delivery with an unknown uterine
scar type unless there is a high clinical suspicion of a previous classical uterine incision.69, 86
Category CUterine closure with interrupted or single-layer continuous locking suture has short-term benefits.
However, the evidence from observational studies of an increased risk of scar rupture may favor the
use of double-layer closure pending evidence on this outcome from randomized trials.14, 26-27
Misoprostol should not be used for third trimester cervical ripening or labor induction in patients
who have had a cesarean delivery or major uterine surgery.69, 82
Those at high risk for complications (e.g., those with previous classical or T-incision, prior uterine
rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise
contraindicated (e.g., those with placenta previa) are not generally candidates for planned TOLAC.69
Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC.69
REFERENCES1. American Academy of Family Physicians/American
College of Obstetricians and Gynecologists. Maternity and Gynecologic Care. AAFP Reprint No. 261. Kansas City, Missouri. March 1998. Updated February 2008.
2. Sewell JE: Cesarean Section-A brief history. Washington, D.C., American College of Obstetricians and Gynecologists, 1993.
3. www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_01.pdf
4. Menacker F, Hamilton BE. Recent trends in cesarean delivery in the United States. NCHS data brief, no 35. Hyattsville, MD: National Center for Health Statistics. 2010.
5. American College of Obstetricians and Gynecologists. Task Force on Cesarean Delivery Rates. Evaluation of Cesarean Delivery. American College of Obstetricians and Gynecologists. Washington, D.C. 2000.
6. NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights. Final Panel Statement, March 8-10, 2010 http://consensus.nih.gov/2010/vbacstatement.htm (Accessed October 11, 2010)
7. Penn Z; Ghaem-Maghami S Indications for caesarean section. Best Pract Res Clin Obstet Gynaecol. 2001 Feb;15(1):1-15.
8. Smaill FM, Gyte GML. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean sec-tion. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007482. DOI: 10.1002/14651858.CD007482.pub2.
9. Hopkins L, Smaill FM. Antibiotic prophylaxis regimens and drugs for cesarean section. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD001136. DOI: 10.1002/14651858. CD001136.
10. Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a ran-domized, controlled trial [published erratum appears in Am J Obstet Gynecol 2007;197:333]. Am J Obstet Gynecol 2007;196:455.e1–455.e5.
11. Antimicrobial prophylaxis for cesarean delivery: tim-ing of administration. Committee Opinion No. 465. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:791-2
12. Antibiotic Prophylaxis for Infective Endocarditis. ACOG Committee Opinion No.421. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;112:1193–4.
13. Guidelines for Perinatal Care, Sixth Edition. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. October 2007
14. Hofmeyr JG, Novikova N, Mathai M, Shah A.Techniques for cesarean section Am J Obstet Gynecol. 2009 Nov;201(5):431-44.
15. Mathai M, Hofmeyr G.J. Abdominal surgical incisions for cesarean section, Cochrane Database Syst Rev 1 (2007) CD004453.
16. Federici D, Lacelli B, Muggiasca A, et al: Cesarean section using the Misgav Ladach method. International J of Gynecol and Obstet. 1997;57:273.
17. Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura EA. Is the formation of a bladder flap at cesar-ean necessary? A randomized trial. Obstet Gynecol 98 (2001), pp. 1089–1092
34 — — Chapter Q: Cesarean Delivery
18. Alexander JM et al Fetal injury associated with cesar-ean delivery. Obstet Gynecol. 2006 Oct;108(4):885-90.
19. Smith JF, Hernandez C, Wax JR. Fetal Laceration Injury at Cesarean Delivery Obstet Gynecol. 1997 Sep;90(3):344-6.
20. Cromi A et al Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques. Am J Obstet Gynecol. 2008 Sep;199(3):292.e1-6.
21. Shipp TD; Zelop CM; Repke JT; Cohen A; Caughey AB; Lieberman E Intrapartum uterine rupture and dehiscence in patients with prior lower uterine seg-ment vertical and transverse incisions. Obstet Gynecol 1999 Nov;94(5 Pt 1):735-40.
22. Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004737.
23. Güngördük K, Yildirim G, Ark C. Is routine cervical dilatation necessary during elective caesarean sec-tion? A randomised controlled trial. Aust N Z J Obstet Gynaecol. 2009 Jun;49(3):263-7.
24. Jacobs-Jokhan D, Hofmeyr G. Extra-abdominal versus intra-abdominal repair of the uterine incision at cesar-ean section, Cochrane Database Syst Rev 4 (2004) CD000085.
25. Walsh CA, Walsh, SR Extraabdominal vs intraabdomi-nal uterine repair at cesarean delivery: a metaanalysis Am J Obstet Gynecol 2009 June; 200(6): 625.e1-625.e8
26. Dodd JM, Anderson ER, Gates S. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004732.
27. Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL. Single- versus double-layer uterine incision closure and uterine rupture. J Matern Fetal Neonatal Med 19 (2006), pp. 639–643.
28. Bamigboye AA, Hofmeyr GJ. Closure versus non-clo-sure of the peritoneum at cesarean section, Cochrane Database Syst Rev 4 (2003) CD000163.
29. Chelmow D; Rodriguez EJ; Sabatini MM Suture closure of subcutaneous fat and wound disruption after cesar-ean delivery: a meta-analysis. Obstet Gynecol 2004 May;103(5 Pt 1):974-80.
30. Anderson ER, Gates S. Techniques and materials for closure of the abdominal wall in caesarean section. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004663. DOI: 10.1002/14651858.CD004663.pub2.
31. Croce P, Frigoli A, Perotti D, Di Mario M. [Cesarean section, techniques and skin suture material] Taglio cesareo, tecniche e materiali di sutura della cute. Minerva ginecologica. 59(6):595-9, Dec 2007
32. Alderdice F, McKenna D, Dornan J. Techniques and materials for skin closure in caesarean section. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003577. DOI: 10.1002/14651858.CD003577.
33. Cromi A, et al Cosmetic outcomes of various skin clo-sure methods following cesarean delivery: a random-ized trial. Am J Obstet Gynecol. 2010 Jul;203(1):36.e1-8. Epub 2010 Apr 24.
34. Rousseau JA, Girard K, Turcot-Lemay L, Thomas N. A randomized study comparing skin closure in cesarean sections: staples vs subcuticular sutures. Am J Obstet Gynecol. 2009 Mar;200(3):265.e1-4.
35. Mangesi L, Hofmeyr GJ. Early compared with delayed oral fluids and food after cesarean section. Cochrane Database Syst Rev 3 (2002) CD003516.
36. Maharaj D, Bagratee JS, Moodley J. Drainage at cesar-ean section–a randomized prospective study, S Afr J Surg 38 (2000), pp. 9–12.
37. Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterec-tomy? Five cases reported. Br J Obstet Gynaecol. 1997 Mar;104(3):372-5.
38. Smith KL, Baskett TF. Uterine compression sutures as an alternative to hysterectomy for severe post-partum hemorrhage. J Obstet Gynaecol Can. 2003 Mar;25(3):197-200.
39. http://www.cbl.uk.com/2008/02/description-of-tech-nique/ accessed March 10, 2011
40. Joshi V; Otiv S; Majumder R; Nikam Y; Shrivastava M Internal iliac artery ligation for arresting postpartum haemorrhage. BJOG. 2007 Mar;114(3):356-361. Epub 2007 Jan 22.
41. Bakri, YN, Amri, A, Abdul Jabbar, F. Tamponade-balloon for obstetrical bleeding. Int J Gynaecol Obstet 2001; 74:139.
42. http://www.cookmedical.com/wh/content/mmedia/WH-BWE-BPPT-EN-200812.ppt accessed March 10, 2011
43. Phipps MG; Watabe B; Clemons JL; Weitzen S; Myers DL Risk factors for bladder injury during cesarean delivery. Obstet Gynecol 2005 Jan;105(1):156-60.
44. Nielson TF, Hokegard K-H: Cesarean section and intra-operative surgical complications. Acta Obstet Gynecol Scand 63:103-108, 1984
45. Jones OH: Casarean section in present-day obstetrics. Am J Obstet Gynecol 126:521, 1976
46. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2009; 7:47.
47. Hawkins JL, Koonin LM, Palmer SK: Anesthesia related deaths during obstetric delivery in the United States, 1979 – 1990. Anesthesiology 1997;86:277.
48. Afolabi BB, Lesi FE, Merah NA. Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004350.
49. Minig L, Trimble EL, Sarsotti C, Sebastiani MM, Spong CY. Building the evidence base for postopera-tive and postpartum advice. Obstet Gynecol. 2009 Oct;114(4):892-900.
— Chapter Q: Cesarean Delivery — 35
50. Martens MG Kolrud BL et al Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases. J Reprod Med 1995 Mar ; 40(3) 171-5
51. Hirsh, J, Guyatt, G, Albers, GW, et al. Executive sum-mary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:71S
52. Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008 Nov 6;359(19):2025-33.53. Silver RM et al Maternal morbid-ity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226-32.
54. Ananth CV; Smulian JC; Vintzileos AM The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis. Am J Obstet Gynecol 1997 Nov;177(5):1071-8.
55. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol. 2006 Jul;108(1):235-7.
56. Kotaska A, et al SOGC clinical practice guideline: Vaginal delivery of breech presentation: no. 226, June 2009. Int J Gynaecol Obstet. 2009 Nov;107(2):169-76.
57. Su M, McLeod L, Ross S et al., Factors associated with adverse perinatal outcome in the Term Breech Trial, Am J Obstet Gynecol 189 (3) (2003), pp. 740–745.
58. Leeman LM. Prenatal Counseling Regarding Cesarean Delivery Obstetrics and Gynecology Clinics of North America 2008 35:3:473-495
59. Hofmeyr GJ, Hannah M. Planned caesarean sec-tion for term breech delivery. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD000166. DOI: 10.1002/14651858.CD000166.
60. Shoulder dystocia. ACOG Practice Bulletin No. 40. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002;100:1045–50.
61. Chauhan, SP, Grobman, WA, Gherman, RA, et al. Suspicion and treatment of the macrosomic fetus: A review. Am J Obstet Gynecol 2005; 193:332.
62. Rouse DJ, Owen J, Goldenberg RL, et al: The effec-tiveness and cost of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA 1996;276:1480. (Level III)
63. Boulvain M, Stan CM, Irion O. Elective delivery in diabetic pregnant women. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD001997. DOI: 10.1002/14651858.CD001997.
64. Irion O, Boulvain M. Induction of labour for suspected fetal macrosomia. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD000938. DOI: 10.1002/14651858.CD000938.
65. Katz VL, Dotters DJ, Droegemueller W: Perimortem cesarean delivery. Obstet Gynecol 1986;68:571. (Level III)
66. American Heart Association Advanced Cardiovascular Life Support Resource Text. 2008
67. Vaginal Birth after Cesarean (VBAC). Agency for Healthcare Research and Quality. AHRQ Publication No. 03-E018. March 2003, Rockville, MD.
69. Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450–63.
70. Spong CY et al Risk of Uterine Rupture and Adverse Perinatal Outcome at Term After Cesarean Delivery. Obstet Gynecol. 2007 Oct;110(4):801-807.
71. Nisenblat V, Barak S, Griness OB, Degani S, Ohel G, Gonen R. Maternal complications associated with multiple cesarean deliveries. Obstet Gynecol 2006;108:21–6.
72. Cahill A, Stamilio DM, Pare E, Peipert JP, Stevens EJ, Nelson DB, et al. Vaginal birth after cesarean (VBAC) attempt in twin pregnancies: is it safe? Am J Obstet Gynecol 2005;193:1050–5.
73. Varner MW, Thom E, Spong CY, Landon MB, Leveno KJ,Rouse DJ, et al. Trial of labor after one previous cesarean delivery for multifetal gestation. National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU. Obstet Gynecol 2007;110:814–9.
74. Cahill AG, Stamilio DM, Odibo AO, Peipert JF, Ratcliffe SJ, Stevens EJ, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006;195:1143–7.
75. Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ,Rouse DJ, et al. Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor? Eunice Kennedy Shriver National Institute of Child
76. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD004224. DOI: 10.1002/14651858.CD004224.pub2.
77. Landon MB et al National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004 Dec 16;351(25):2581-9. Epub 2004 Dec 14.
78. Halperin ME; Moore DC; Hannah WJ Classical versus low-segment transverse incision for preterm caesar-ean section: maternal complications and outcome of subsequent pregnancies. Br J Obstet Gynaecol 1988 Oct;95(10):990-6.
79. Ridgeway JJ; Weyrich DL; Benedetti TJ Fetal heart rate changes associated with uterine rupture. Obstet Gynecol 2004 Mar;103(3):506-12.
80. Leung AS; Leung EK; Paul RH Uterine rupture after previous cesarean delivery: maternal and fetal conse-quences. Am J Obstet Gynecol 1993 Oct;169(4):945-50.
36 — — Chapter Q: Cesarean Delivery
slide 10, 11
81. Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Obstet Gynecol 2006;108:12–20.
82. Wing DA, Lovett K, Paul RH. Disruption of prior uter-ine incision following misoprostol for labor induction in women with previous cesarean delivery. Obstet Gynecol 1998;91:828–30
83. Sakala EP, Kaye S, Murray RD, Munson LJ. Epidural analgesia. Effect on the likelihood of a successful trial of labor after cesarean section. J Reprod Med 1990;35:886–90.
84. Landon MB, Leindecker S, Spong CY, Hauth JC, Bloom S,Varner MW, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol 2005;193:1016–23.
85. Clock C, Kurtzman J, White J, Chung JH. Cesarean risk after successful external cephalic version: a matched, retrospective analysis. J Perinatol 2009;29:96–100.
86. Leung AS, Farmer RM, Leung EK, Medearis AL, Paul RH.Risk factors associated with uterine rupture dur-ing trial of labor after cesarean delivery: a case-con-trol study. Am J Obstet Gynecol 1993;168:1358–63.
87. Northern New England Perinatal Quality Improvement Network VBAC Guidelines http://www.nnepqin.org/images/VBAC%20Guideliens%20NNEPQIN%201%2006%2005.doc (Accessed April 12, 2010)
88. Shelhass CS, Gilbert S, Landon MB, et al. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol August 2009, Vol 114 (2) 224-229.
89. Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol. 1985 Sep;66(3):353-6
90. Tita ATN, Landon MB, Spong CY, et al. Timing of Elective Repeat Cesarean Delivery and Term and Neonatal Outcomes. N Engl J Med 2009;360:111-20.
— Chapter Q: Cesarean Delivery — 37
INFORMATION ABOUT TRIAL OF LABOR AND VAGINAL DELIVERY AFTER CESAREAN DELIVERY
Many women in the United States deliver their babies by Cesarean Delivery, an operation where the baby is born
through an incision, or cut, in the mother’s abdomen and uterus. For many years doctors believed that if a mother
had one cesarean delivery, she must have another cesarean delivery to deliver any other babies. Studies have
shown that it is safe for most women who have had a Cesarean delivery in the past to try to have a vaginal birth.
This is called a “Trial Of Labor After Cesarean” or TOLAC, and if she is successful she has had a “Vaginal Birth
After Cesarean” or VBAC.
Although it is safe for most women to try a TOLAC/VBAC there are some women with risk factors that might
make it unsafe. Your provider will review your history and records to find out if you would be a good candidate
for a TOLAC/VBAC. Many experts encourage mothers who do not have risk factors to attempt a TOLAC/VBAC.
At [INSERT YOUR MEDICAL CENTER/HOSPITAL NAME HERE] we feel that it is the best choice for many of our
patients. About three out of four women (75 percent) attempting a TOLAC will be successful.
There are some advantages and some risks to either having a repeat Cesarean Delivery or a TOLAC/VBAC.
There are some risks to both these choices. The decision about whether to try a TOLAC/VBAC is a very personal
one. This information sheet provides general facts about repeat Cesarean Delivery and TOLAC/VBAC. Please
discuss your personal case with your provider to help you make the right decision for you.
ADVANTAGES TO YOU OF HAVING A TOLAC/VBAC:
– Less risk to the mother. Women who have a vaginal birth have less chance of getting an infection.
Usually there is less bleeding and less risk of needing a blood transfusion.
– Shorter recovery time. Most women can leave the hospital one or two days after a vaginal birth. Most
women stay at least two to three days after a Cesarean Delivery. After going home, women who have had a
vaginal delivery usually go back to normal activities sooner than those who have had a Cesarean Delivery.
There is usually less pain after a vaginal delivery.
– More involvement in the birth. Many women feel a vaginal delivery allows them to be more involved in
the birth. After a vaginal delivery the mother can usually hold the baby right away and begin breast-feeding.
After a Cesarean Delivery, the mother often can’t hold the baby or breastfeed until the operation is over
and the mother recovers from anesthesia. More than one family member may be in the room for a vaginal
delivery if the patient wishes. Only one person can be in the room for a Cesarean Delivery. If the mother
needs general anesthesia (goes to sleep) no one is allowed to be in the operating room.
– Future pregnancies. Women who have a successful vaginal birth after cesarean will have less risk of
complications with future pregnancies compared to women having a repeat cesarean delivery.
DISADVANTAGES OF A TOLAC:
– Unsuccessful labor. Not all women who try to have a vaginal delivery are successful. Mothers who need
a repeat Cesarean Delivery after an unsuccessful labor may have more risk of infection, bleeding and
blood transfusion or injury to nearby organs such as the bowel and bladder. About three out of four (75
percent) women who try a TOLAC will have a successful VBAC. The chance of a successful VBAC is higher
if a woman has had a vaginal delivery in the past.
APPENDIX 1
38 — — Chapter Q: Cesarean Delivery
– Rupture of the uterus. There is a small chance that the scar in the uterus from the previous Cesarean
Delivery may rupture, or come apart, in labor. If this happens, an emergency Cesarean Delivery is required.
There is a risk that the baby may suffer serious injury or death. At [INSERT YOUR MEDICAL CENTER/
HOSPITAL NAME HERE], there are staff in the hospital 24 hours a day to do an emergency Cesarean
Delivery. In most cases the baby is delivered before it is harmed. Rupture of the uterus also increases
the risk to the mother of injury to the nearby tissues, such as the bladder or bowel. There is also a risk of
needing a hysterectomy. The risk of rupture is higher if you have had more than one Cesarean Delivery in
the past and lower if you have had a vaginal delivery in the past.
OTHER ISSUES: – Pain. Many women worry that labor may be painful and that a Cesarean Delivery will mean they don’t have to
go through the pain of labor. Although labor is painful, there are many ways to give pain relief. Medicine may
be given through an IV and this works for many patients. Epidurals (a procedure that numbs the abdomen
so that the patient does not feel labor pains) are available for women who want them. Women who have a
Cesarean Delivery usually have more pain for a longer time than women who have a vaginal birth.
– Labor induction. The medicine oxytocin (Pitocin) is used to start labor or help it along if it is not progressing
normally. Many studies show that Pitocin does not increase the risk of problems for women undergoing
TOLAC/VBAC if used to help a labor that has already begun. If Pitocin is used to start labor (induction) the
chance of uterine rupture increases from about one in 200 to one in 100 women. At [INSERT YOUR MEDICAL
CENTER/HOSPITAL NAME HERE] we use Pitocin in patients trying a TOLAC/VBAC if it is needed.
– Monitoring. Patients trying a TOLAC/VBAC at [INSERT YOUR MEDICAL CENTER/HOSPITAL NAME
HERE] have continuous monitoring of the baby’s heart rate and uterine contractions. Also an IV will be
placed. This helps us to identify problems and do a Cesarean Delivery quickly if necessary.
This information should help you decide if you want a TOLAC/VBAC or a repeat cesarean delivery for the birth
of your baby. Please talk to your provider about any questions you have so that you may get the information you
need to help make this choice. It may also help to talk to family members. For either decision you make, our goal
is to provide you with the best possible care for a good outcome — a healthy mother and healthy baby.
I have read the information sheet and have had the chance to discuss it with my provider. Any questions I had
have been answered to my satisfaction.
_____ I choose a trial of labor and vaginal birth after cesarean delivery
_____ I choose to have a repeat cesarean delivery
_______________________________________________ ______________________________________________ __________________________Patient (please print) Patient Signature Date
_______________________________________________ ______________________________________________ __________________________Provider (please print) Provider Signature Date
_______________________________________________ ______________________________________________ __________________________Witness (please print) Witness Signature Date
Adapted from the University of New MexicoDeveloped by Tony Ogburn, MD and Larry Leeman, MD